Factors contributing to in-hospital infections in elderly ICU patients post-antibiotics: A risk prediction model.

In elderly ICU patients, the prevalence of skeletal muscle loss is high. Longitudinal effect of thoracic muscles, especially in elderly ICU patients, are unclear although skeletal muscle loss is related with the short- and long-term outcomes. This study aimed to evaluate whether pectoralis muscle mass loss could be a predictor of prognosis in elderly ICU patients. We retrospectively evaluated 190 elderly (age > 70 years) patients admitted to the ICU. We measured the cross-sectional area (CSA) of the pectoralis muscle (PMCSA) at the fourth vertebral region. CT scans within two days before ICU admission were used for analysis. Mortality, prolonged mechanical ventilation, and longitudinal changes in Sequential Organ Failure Assessment (SOFA) scores were examined. PMCSA below median was significantly related with prolonged ventilation (odds ratio 2.92) and a higher SOFA scores during the ICU stay (estimated mean = 0.94). PMCSA below median was a significant risk for hospital mortality (hazards ratio 2.06). In elderly ICU patients, a low ICU admission PMCSA was associated with prolonged ventilation, higher SOFA score during the ICU stay, and higher mortality. Adding thoracic skeletal muscle CSA at the time of ICU admission into consideration in deciding the therapeutic intensity in elderly ICU patients may help in making medical decisions.

Objective To study the predictive value of acute gastrointestinal injury (AGI) grading system introduced into Sequential Organ Failure Assessment (SOFA) score in patients with severe acute pancreatitis (SAP) in order to provide a reliable clinical tool for the evaluation of prognosis of SAP. Methods Patients with acute pancreatitis admitted to ICU from July 2012 to July 2014 were enrolled for study. The criteria of exclusion were the age below 18 years old, pregnancy, or patients without consent to the treatment. A total of 63 patients with 37 males and 26 females aged (47 ±15.3) years were included. The data of their acute physiology and chronic health evaluation (APACHE) Ⅱ score, the highest SOFA score and AGI grade within the first week, and the 28-day mortality rate were collected. Patients without AGI were defined as zero point, and AGI grade I -IV were defined as 1-4 points. The receiver operating characteristic curve (ROC) was used to evaluate the value of APACHEⅡ score, SOFA score, and SOFA + AGI score in predicting the prognosis of SAP. The areas under ROC curve (AUC) of the APACHEⅡ score, SOFA score, and SOFA +AGI score were compared with MedCalc software, and P value less than 0.01 was considered to be statistical significance. Results (1) The 28-day mortality of the 63 patients with SAP was 20.6% (13/63), in which 50 patients in the survival group, 13 patients in the death group. The APACHEⅡ scores of two groups were (15.62 ± 4.33 vs. 12.10 ± 3.74, P =0.0048), the SOFA scores were (14.77 ± 3.09 vs. 9.24 ± 2.88, P <0.01), and the SOFA +AGI scores were (18.77 ± 3.09 vs. 10.74 ± 3.17, P <0.01). (2) The AUC of APACHEⅡ score was 0.748 ± 0.084 (95% CI: 0.622-0.849), the AUC of SOFA score was 0.902 ± 0.059 (95% CI: 0.801-0.962), and the AUC of SOFA +AGI score was 0.963 ± 0.037 (95% CI, 0.882-0.994) ; There was no significant difference in AUC between APACHEⅡ score and SOFA score (P =0.10) , and there was statistical significance between the AUC of APACHEⅡ score and that of SOFA +AGI score (P =0.013) , and the difference in AUC between SOFA score and SOFA +AGI score was statistically significant (P =0.008). The Youden index and the positive likelihood ratio of SOFA +AGI score system were the greatest to be 0.863 and 15.38, respectively. Conclusions SOFA scoring system has better predictive value in patients with SAP when AGI grading system was introduced into it. Key words: Acute gastrointestinal injury grading system; APACHEⅡ score; SOFA score; Severe acute pancreatitis; Prognosis

Background Despite the remarkable advances in the treatment options of acute heart failure (HF), prognosis assessment remains an ongoing challenge. Previous studies revealed only a moderate accuracy of models predicting mortality. Sequential Organ Failure Assessment (SOFA) Score are widely used in the intensive care unit (ICU) to predict outcome and predicted higher long-time mortality in unselected patients in cardiac ICU. In addition, the American Heart Association Get With the Guidelines–Heart Failure (GWTG-HF) risk score allows for risk stratification of 30-day outcome for patients hospitalized with HF. The purpose of this study was to evaluate whether SOFA score on admission is useful for long-time mortality prediction in acute HF patients and also to assess the discriminative performance as compared with GWTG-HF risk score. Methods This was a single-centre, retrospective cohort study. Between January 2007 and December 2016, we screened eligible 661 consecutive patients with acute HF administered at our hospital. SOFA score on admission of 294 patients was able to calculate retrospectively. We enrolled 269 patients who could complete follow up evaluation for more than 1 year. Endpoint was all-cause mortality after admission. Additive information of SOFA score was evaluated by area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA). Results The 269 patients were included in this study (78.5±10.9 years; 136 men; left ventricular ejection fraction [EF], 49.8±16.6%) during a mean follow-up of 32.1±22.3 months. Patients with all-cause death had higher SOFA score (4.2±2.3 versus 2.8±1.8, p&lt;0.001; AUC, 0.689) and GWTG-HF risk score (44.0±7.6 versus 38.1±7.9, P&lt;0.001, AUC, 0.692). Kaplan-Meier survival analysis demonstrated higher SOFA scores (P&lt;0.001) and GWTG-HF risk scores (P&lt;0.001) appears to be related to increase probabilities of all cause death. A multivariate Cox proportional hazard model were made with adjustment for SOFA score, GWTG-HF risk score, age, gender and ejection fraction. As a result, SOFA score (hazard ratio [HR] 1.227; 95% confidence interval [CI], 1.130 to 1.326; P&lt;0.001), GWTG-HF (HR, 1.054; 95% CI, 1.029 to 1.078; P&lt;0.001) and age (HR, 1.069; 95% CI 1.048 to 1.092; P&lt;0.001) were independent predictors of all cause death and HR of SOFA score was the highest in these parameters. Incorporating SOFA score into GWTG-HF score yielded a significant NRI (0.528 (95% CI 0.291 to 0.765) and IDI (0.046 (95% CI 0.020 to 0.072). In DCA, compared with the reference model, the net benefit for SOFA score model was greater across the range of threshold probabilities. Conclusions The SOFA score, simple and validated mortality risk score can predict long-term all-cause mortality in patients with acute HF. Discriminative performance metrics such as NRI, IDI and DCA were improved on incorporation of the SOFA score for prediction of mortality.

Procalcitonin is a biomarker that often is elevated in response to a bacterial infection, whereas viral infections suppress procalcitonin production through interferon-γ.1Becker K.L. Snider R. Nylen E.S. Procalcitonin assay in systemic inflammation, infection, and sepsis: clinical utility and limitations.Crit Care Med. 2008; 36: 941-952Crossref PubMed Scopus (461) Google Scholar The PRORATA trial supported its usefulness in antibiotic stewardship by encouraging antibiotic use for procalcitonin levels of ≥ 0.5 ng/mL and discontinuation of < 0.25 ng/mL in critically ill patients.2Bouadma L. et al.Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial.Lancet. 2010; 375: 463-474Abstract Full Text Full Text PDF PubMed Scopus (901) Google Scholar Procalcitonin can be elevated in COVID-19 because of bacterial coinfection, inflammation, or excessive cytokine production. Studies suggest that procalcitonin level may predict disease severity in COVID-19, but it may not indicate a bacterial infection reliably in this population.3Walkey A.J. et al.The Viral Infection and Respiratory Illness Universal Study (VIRUS): an international registry of coronavirus 2019-related critical illness.Crit Care Explor. 2020; 2e0113Crossref Google Scholar, 4Heer R.S. et al.Elevated procalcitonin concentrations in severe Covid-19 may not reflect bacterial co-infection.Ann Clin Biochem. 2021; 58: 520-527Crossref PubMed Scopus (0) Google Scholar, 5Vanhomwegen C. et al.Procalcitonin accurately predicts mortality but not bacterial infection in COVID-19 patients admitted to intensive care unit.Ir J Med Sci. 2021; 190: 1649-1652Crossref Scopus (28) Google Scholar This study explored the predictive usefulness of procalcitonin levels in identifying culture-proven bacterial infections and demonstrated associated antibiotic use patterns among hospitalized patients with COVID-19. Between March 2020 and June 2022, a total of 7,931 adult patients with COVID-19 hospitalized across various Mayo Clinic sites (Florida, Rochester, Arizona, Mankato, and Eau Claire) were enrolled in the Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study COVID-19 registry (Institutional Review Board Identifier: 20-002610).3Walkey A.J. et al.The Viral Infection and Respiratory Illness Universal Study (VIRUS): an international registry of coronavirus 2019-related critical illness.Crit Care Explor. 2020; 2e0113Crossref Google Scholar A clinical decision support algorithm regarding procalcitonin testing for patients with COVID-19 was available, although its use was not mandatory. Among them, 3,665 patients underwent procalcitonin level check at some point during hospitalization. Seven hundred forty-nine patients underwent culture analysis performed within 5 days of the procalcitonin test and were included in the primary analysis. The primary outcome was the incidence of culture-proven bacterial infection in the first culture sample collected within 5 days of the procalcitonin test, whereas secondary outcomes were any antibiotic use during hospital stay, mortality rates, ICU requirements, and hospital length of stay. Statistical comparison was conducted using a two-sample t test (continuous variables), a Wilcoxon rank-sum test (ordinal variables), or a Fisher exact test (categorical variables) using R version 4.1.2 statistical software (R Foundation for Statistical Computing). Among 749 patients with COVID-19 in the primary analysis, the first procalcitonin measurement was high (≥ 0.25 ng/mL) in 312 patients (41.66%). In 95.2% of patients, the first procalcitonin measurement was reported within 1 day of admission, and 54.1% of patients underwent serial procalcitonin level measurement performed during the hospital stay. Patients in the higher procalcitonin level group were more likely to be male and had a higher incidence of chronic kidney disease and diabetes mellitus (Table 1).Table 1Demographic Features, Laboratory Test Results, Therapeutics, and Outcomes Compared by First Procalcitonin MeasurementVariableOverall (N = 749)Procalcitonin < 0.25 ng/mL (n = 437)Procalcitonin ≥ 0.25 ng/mL (n = 312)P ValueDemographics Age, y64 (52-76)64 (53-76)64 (52-75).44 Sex< .001Female292 (39.0)195 (44.6)97 (31.1)Male457 (61.0)242 (55.4)215 (68.9)Comorbidities Coronary artery disease68 (9.1)41 (9.4)27 (8.7).80 Hypertension350 (46.7)211 (48.3)139 (44.6).33 Congestive heart failure17 (2.3)10 (2.3)7 (2.2)1.00 Chronic pulmonary disease (not asthma)72 (9.6)47 (10.8)25 (8.0).26 Asthma (physician diagnosed)55 (7.3)39 (8.9)16 (5.1).064 Chronic kidney disease91 (12.1)37 (8.5)54 (17.3)< .001 Diabetes mellitus180 (24.0)93 (21.3)87 (27.9).038 Liver disease6 (0.8)3 (0.7)3 (1.0).70 Metastatic cancer28 (3.7)15 (3.4)13 (4.2).70 Obesity55 (7.3)30 (6.9)25 (8.0).57 Dyslipidemia227 (30.3)140 (32.0)87 (27.9).23Laboratory results, therapeutics, and outcomes Procalcitonin, ng/mL0.20 (0.10-0.52)0.11 (0.08-0.16)0.68 (0.38-1.57)< .001 Baseline CRP level, mg/dL79.35 (36.62-139.68)55.10 (22.55-98.00)124.40 (76.55-194.80)< .001 Baseline SOFA score6 (3-9)4 (3-7)7 (4-11)< .001 Bacterial infection, %140 (18.7)73 (16.7)67 (21.5).11 Positive blood culture results, %73/690 (10.6)36/393 (9.2)37/297 (12.5).17 Positive urine culture results, %67/398 (16.8)31/220 (14.1)36/178 (20.2).11 Positive sputum culture results, %49/397 (12.3)23/220 (10.5)26/177 (14.7).22 Positive BAL culture results, %7/120 (5.8)4/45 (8.9)3/75 (4.0).42 Positive ETT culture results, %3/27 (11.1)0/6 (0.0)3/21 (14.3)1.00 Positive respiratory wash results, %0/24 (0.0)0/9 (0.0)0/15 (0.0)— Positive other culture results, %2/35 (5.7)1/15 (6.7)1/20 (5.0)1.00 ICU admission rate307 (41.0)125 (28.6)182 (58.3)< .001 Antibiotics use, %595 (79.4)295 (67.5)300 (96.2)< .001 Antibiotic use durationEntire hospital stay5.0 (1.0-9.0)2.0 (0.0-6.0)8.0 (5.0-15.0)< .001During ICU stay7.0 (3.0-16.0)5.0 (1.0-11.0)8.5 (5.0-18.0).010 Steroids556 (74.2)292 (66.8)264 (84.6)< .001 Hospital discharge status< .001Alive660 (88.1)407 (93.1)253 (81.1)Dead89 (11.9)30 (6.9)59 (18.9) Length of stay, dHospital7.1 (4.3-15.0)5.5 (4.0-10.3)11.0 (6.0-21.9)< .001ICU8.9 (4.2-19.2)6.5 (3.5-13.9)10.7 (5.3-23.5).012Subgroup analysis of patients already receiving antibiotic therapy at the time of first procalcitonin measurementn = 441n = 236n = 205 Contiguous antibiotic duration, d5.0 (2.0-8.0)4.0 (2.0-6.0)6.0 (4.0-9.0)< .001Data are presented as No. (%), No./Total No. (%), or median (interquartile range). P values result from a two-sample t test (continuous variables) or a Fisher's exact test (categorical variables). The following organisms are excluded from the culture-positive results: blood culture, Staphylococcus epidermidis; urine culture, mixed flora; respiratory culture, Candida. CRP = C-reactive peptide; SOFA = Sequential Organ Failure Assessment. Open table in a new tab Data are presented as No. (%), No./Total No. (%), or median (interquartile range). P values result from a two-sample t test (continuous variables) or a Fisher's exact test (categorical variables). The following organisms are excluded from the culture-positive results: blood culture, Staphylococcus epidermidis; urine culture, mixed flora; respiratory culture, Candida. CRP = C-reactive peptide; SOFA = Sequential Organ Failure Assessment. The median interval between the procalcitonin level results and the culture examination results was 0.85 days (interquartile range, 0.0-1.6 days). The overall incidence of culture-proven bacterial infection in the cohort was 18.7%, which did not vary statistically between patients in the high (≥ 0.25 ng/mL) and low (< 0.25 ng/mL) procalcitonin groups (21.5% vs 16.7%; P = .11). However, overall antibiotic use during the hospitalization was disproportionately high (79.4%) and much higher in the high procalcitonin group (96.2% vs 67.5%). Antimicrobial duration was significantly shorter among patients with a low procalcitonin level (2 days vs 8 days for overall hospital stay; 5 days vs 8.5 days for ICU stay). Among patients who already were taking antibiotics at the time of the first procalcitonin level measurement (n = 441), the duration of contiguous antibiotic use also was shorter in the low procalcitonin group (4 days vs 6 days). Baseline Sequential Organ Failure Assessment score, C-reactive peptide level, ICU admission, hospital length of stay, and mortality rates were significantly higher with elevated procalcitonin levels (Table 1). Among all patients who were enrolled in the study and had a culture results available, the overall incidence of culture-proven bacterial infection was low (5.2%) and not significantly different between patients with and without procalcitonin level measurement (4.8% vs 5.5%). Those whose procalcitonin level was measured showed a lower baseline Sequential Organ Failure Assessment score, but higher antibiotic use (66.0% vs 47.9%) and worse hospital outcomes (Table 2).Table 2Comparison of Demographic Features, Laboratory Findings, Therapeutics, and Outcomes Among Hospitalized Patients With COVID-19 With and Without Procalcitonin Level MeasurementVariableOverall (N = 7,922)No Procalcitonin Level Measurement (n = 4,257)Procalcitonin Level Measurement (n = 3,665)P ValueDemographics Age, y65 (51-76)64 (50-76)65 (53-76)< .001 Sex< .001Female3,409 (43.0)1,929 (45.3)1,480 (40.4)Male4,513 (57.0)2,328 (54.7)2,185 (59.6)Comorbidities Coronary artery disease739 (9.3)402 (9.4)337 (9.2).73 Hypertension3,395 (42.9)1,718 (40.4)1,677 (45.8)< .001 Congestive heart failure244 (3.1)148 (3.5)96 (2.6).031 Chronic pulmonary disease (not asthma)708 (8.9)363 (8.5)345 (9.4).18 Asthma (physician diagnosed)726 (9.2)408 (9.6)318 (8.7).17 Chronic kidney disease839 (10.6)444 (10.4)395 (10.8).63 Diabetes mellitus1,897 (23.9)996 (23.4)901 (24.6).22 Liver disease50 (0.6)31 (0.7)19 (0.5).26 Metastatic cancer377 (4.8)204 (4.8)173 (4.7).92 Obesity611 (7.7)323 (7.6)288 (7.9).67 Dyslipidemia2,435 (30.7)1,229 (28.9)1,206 (32.9)< .001Laboratory findings, therapeutics, and outcomes Baseline CRP level, mg/dl63.80 (26.20-120.10)54.70 (21.60-110.75)71.15 (32.42-127.38)< .001 Baseline SOFA score5 (3-7)5 (3-9)4 (3-7)< .001 Bacterial infection, %408 (5.2)206 (4.8)202 (5.5).18 ICU admission rate,%2,036 (25.7)1,043 (24.5)993 (27.1).009 Antibiotics use, %4,458 (56.3)2,039 (47.9)2,419 (66.0)< .001 Antibiotic use durationEntire hospital stay1.0 (0.0-5.0)0.0 (0.0-5.0)2.0 (0.0-6.0)< .001During ICU stay4.0 (1.0-9.0)2.0 (0.0-7.0)5.0 (2.0-11.0)< .001 Steroids5,401 (68.2)2,711 (63.7)2,690 (73.4)< .001 Hospital discharge status.020Alive7,335 (92.6)3,969 (93.2)3,366 (91.8)Dead587 (7.4)288 (6.8)299 (8.2) Length of stay, dHospital5.3 (3.6-9.9)5.0 (3.0-8.9)6.0 (4.1-10.9)< .001ICU5.0 (2.0-11.9)3.9 (1.5-9.5)6.6 (3.0-14.6)< .001Data are presented as No. (%) or median (interquartile range). P values result from a two-sample t test (continuous variables) or a Fisher's exact test (categorical variables). The following organisms were excluded from the culture-positive results: blood culture, Staphylococcus epidermidis; urine culture, mixed flora; and respiratory culture, Candida. A total of 8,098 patients with COVID-19 were enrolled in the Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study registry during the study period; 167 patients younger than 18 years were excluded and nine patients were excluded because of missing variables. CRP = C-reactive peptide; SOFA = Sequential Organ Failure Assessment. Open table in a new tab Data are presented as No. (%) or median (interquartile range). P values result from a two-sample t test (continuous variables) or a Fisher's exact test (categorical variables). The following organisms were excluded from the culture-positive results: blood culture, Staphylococcus epidermidis; urine culture, mixed flora; and respiratory culture, Candida. A total of 8,098 patients with COVID-19 were enrolled in the Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study registry during the study period; 167 patients younger than 18 years were excluded and nine patients were excluded because of missing variables. CRP = C-reactive peptide; SOFA = Sequential Organ Failure Assessment. On assessing the performance of procalcitonin in predicting culture-proven bacterial infection, a cutoff of 0.25 ng/mL showed 47.9% sensitivity, 59.8% specificity, positive predictive value of 21.5%, negative predictive value (NPV) of 83.3%, and Youden's index of 0.08. Among patients with the first procalcitonin level within 48 h of admission (n = 728), the sensitivity, specificity, positive predictive value, NPV, and Youden index were 47.8%, 60.0%, 21.5%, 83.3%, and 0.08, respectively. In this multicenter study of hospitalized patients with COVID-19, the incidence of culture-proven bacterial infection was low among both patients with and without procalcitonin level measurement. However, the use and duration of antibiotic therapy were disproportionately high, especially in patients with higher procalcitonin levels. Although the sensitivity and specificity of procalcitonin level for culture-proven bacterial infection were relatively low, NPV was high (83.3%). Patients with higher procalcitonin level also showed higher baseline Sequential Organ Failure Assessment scores and worse outcomes, indicating a potential association between procalcitonin elevation and disease severity. These findings align with the existing literature.4Heer R.S. et al.Elevated procalcitonin concentrations in severe Covid-19 may not reflect bacterial co-infection.Ann Clin Biochem. 2021; 58: 520-527Crossref PubMed Scopus (0) Google Scholar,5Vanhomwegen C. et al.Procalcitonin accurately predicts mortality but not bacterial infection in COVID-19 patients admitted to intensive care unit.Ir J Med Sci. 2021; 190: 1649-1652Crossref Scopus (28) Google Scholar Several observational studies have explored the usefulness of procalcitonin to predict bacterial coinfection in COVID-19 and have found elevated procalcitonin to be ineffective in identifying coinfections and having poor predictive value. However, they did find that a procalcitonin threshold of < 0.25 ng/mL had a high NPV for excluding coinfection, aligning with our study.6Carbonell R. et al.Negative predictive value of procalcitonin to rule out bacterial respiratory co-infection in critical covid-19 patients.J Infect. 2022; 85: 374-381Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,7May M. et al.Limited utility of procalcitonin in identifying community-associated bacterial infections in patients presenting with coronavirus disease 2019.Antimicrob Agents Chemother. 2021; 65Crossref Scopus (32) Google Scholar Given its relatively high NPV, a low procalcitonin level therefore could aid in ruling out bacterial coinfection and guiding antibiotic therapy in COVID-19, although further research is warranted to assess its role in the noninitiation of antibiotics or safe antibiotic discontinuation. Clinical suspicion of superimposed infection often leads to antibiotic initiation, and in the presence of elevated procalcitonin level, antibiotic therapy often is continued. However, a low procalcitonin level during ongoing antibiotic therapy may help in early antibiotic discontinuation, as found in our study. Studies have shown that continuing empirical antibiotics without confirmed nosocomial infection is associated with worse outcomes in critically ill patients.8Aarts M.A. et al.Antibiotic management of suspected nosocomial ICU-acquired infection: does prolonged empiric therapy improve outcome?.Intensive Care Med. 2007; 33: 1369-1378Crossref PubMed Scopus (33) Google Scholar,9Garnacho-Montero J. et al.De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock.Intensive Care Med. 2014; 40: 32-40Crossref PubMed Scopus (292) Google Scholar Moreover, we also found that procalcitonin testing was associated with higher antibiotic use and longer hospital stays, despite a similar incidence of culture-proven bacterial infection, contrary to prior studies.10Hessels L.M. Speksnijder E. Paternotte N. et al.Procalcitonin-guided antibiotic prescription in patients with COVID-19: a multicenter observational cohort study.Chest. 2023; 164: 596-605Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar In summary, this study demonstrated that procalcitonin has limited sensitivity and specificity for bacterial coinfections in COVID-19 pneumonia and instead could be a marker of inflammatory process. Because of the possible adverse effects resulting from inappropriate antibiotic exposure in the absence of infection, clinicians should be cautious while interpreting procalcitonin levels in this population. This multicenter study provides diverse data from all waves of the COVID-19 pandemic, enhancing the generalizability of findings. However, limitations include the lack of causality resulting from its retrospective design, the effect of unexplored confounders such as the possibility of culture-negative infections, as well as variations in serial procalcitonin testing. The authors have reported to CHEST Critical Care the following: R. K. has received grant and contracts from the Gordan and Betty Moore Foundation and Jenssen and Jenssen LLC; all payments made to the institution. None declared (S. I., P. S., L. R., S. J., A. J., A. J. H., E. C. C., A. Balavenkataraman, A. T., V. B., S. M. C., S. A. K., N. K. J., A. T. L., R. C.-C., B. M. P., R. D. M., C. P. V., A. B. S., A. Bhattacharyya, S. C., S. P. K., Y. M. E., Q. J. Q., N. M. P., P. K. G., P. M. F., D. K. S., A. R.). Other contributions: The authors thank all the members of the Acute Care Research Consortium, Department of Critical Care Medicine, Mayo Clinic Florida, for their continuous support and valuable contributions toward the successful conduction of this study.

Background The Sequential Organ Failure Assessment (SOFA) score can help to assess organ failure over time and is useful to evaluate morbidity. The aim of this study is to evaluate the performance of SOFA score as a descriptor of multiple organ failure in critically ill patients in a local unit hospital, and to compare with APACHE III scoring system. Methods This study was carried out prospectively. A total of ninety one patients were included who admitted to the medical intensive care unit (ICU) in Chuncheon Sacred Heart Hospital from May 1 through June 30, 2000. We excluded patients with a length of stay in the ICU less than 2 days following scheduled procedure, admissions for ECG monitoring, other department and patients transferred to other hospital. The SOFA score and APACHE III score were calculated on admission and then consecutively every 24 hours until ICU discharge. Results The ICU mortality rate was 20%. The non-survivors had a higher SOFA score within 24 hours after admission. The number of organ failure was associated with increased mortality. The evaluation of a subgroup of 74 patients who stayed in the ICU for at least 48 hours showed that survivors and non-survivors followed a different course. In this subgroup, the total SOFA score increased in 81% of the non-survivors but in only 21% of the survivors. Conversely, the total SOFA score decreased in 48% of the survivors compared with 6% of the non-survivors. The non-survivors also had a higher APACHE III score within 24 hours and there was a correlation between SOFA score and APACHE III score. Conclusion The SOFA score is a simple, but effective method to assess organ failure and to predict mortality in critically ill patients. Regular and repeated scoring enables patient's condition and clinical course to be monitored and better understood. The SOFA score well correlates with APACHE III score.

Background: The Sequential Organ Failure Assessment (SOFA) score is an excellent tool for assessing the extent of organ dysfunction in critically ill patients. This study was planned to compare outcome and organ failure status of community (CAARF) and hospital acquired acute renal failure (HAARF) patients requiring dialysis using SOFA score.Methods: The present prospective observational study was conducted on fifty consecutive acute renal failure patients age more than 18 years of either sex requiring dialysis. Patients who developed ARF after 24 hours of admission were referred as HAARF and patients who had acute renal failure on admission were considered as CAARF. The Sequential Organ Failure Assessment (SOFA) score was used to track a patient's status during the stay in an intensive care unit in both HAARF and CAARF patients.Results: Out of 50 patients, 31(62%) patients had community acquired renal failure and 19 (38%) patients had hospital acquired renal failure. Mean SOFA in HAARF patients was high (8.84±3.13) compare to CAARF patients (6.16± 2.80). The p value calculated was 0.003 which was significant. High SOFA Score (&gt;11) were seen predominantly in HAARF (83.3%) patients compare to CAARF (16.7%), followed by 57.1% of patients in HAARF and 42.9% of patients in CAARF had SOFA score between 9 to11.Conclusions: High SOFA Score were seen predominantly in HAARF patients compare to CAARF and so poor outcome compare to CAARF. So, SOFA score may be used in explaining prognosis and outcome of ARF patients.

Introduction: The Sequential Organ Failure Assessment (SOFA) score predicts intensive care unit (ICU) mortality within a medical ICU population but utility of the SOFA score in the contemporary cardiac ICU (CICU) is unclear. Methods: Data from consecutive patients with primary cardiac (PC) and non-cardiac (PNC) disease admitted to the CICU at a tertiary care center from 1/1/19-2/28/19 and 10/1/19-11/30/19 were collected and analyzed by retrospective chart review, including demographics, comorbidities, primary reasons for admission, labs and SOFA score parameters. Patients were grouped into three categories based on their highest SOFA score within the first 24 hours of CICU admission: SOFA Score ≤ 6, 7-11 and ≥ 12. CICU and in-hospital mortality rates (adjusted for age, gender, race, and comorbidities) were compared using multivariate linear regression. Results: Of the 453 patients admitted to the CICU during the studied time period, 321 had PC diagnoses and 132 PNC diagnoses. The mean age was 63.5 and 59.6 ( p&lt; 0.05) , 65.1% and 50.7% were male ( p&lt; 0.05) , and 53.6% and 62.9% were white ( p=0.07) , and 70.4% and 56.8% had at least three or more comorbidities ( p&lt;0.05) for the PC and PNC cohorts, respectively. The top three comorbidities were hypertension (70%), heart failure (39%), and diabetes mellitus (36%) for the PC group and hypertension (60%), diabetes mellitus (33%), and pulmonary disease (26%) for the PNC group, respectively. Increasing SOFA scores were associated with increased CICU and in-hospital mortality (Table) for patients with both PC and PNC diagnoses. Conclusion: Increased SOFA scores were associated with higher risk of CICU and in-hospital mortality. The SOFA score may be useful for risk stratification of CICU patients with both primary cardiac and non-cardiac diagnoses.

To analyze the early diagnostic value of plasma soluble cluster of differentiation 14 subtype (sCD14-ST, Presepsin) in sepsis in a population with suspected sepsis in fever clinic. A prospective observational study was conducted. The patients admitted to the fever clinic of Beijing Chaoyang Hospital from April to December 2022 were enrolled as the study objects. According to sequential organ failure assessment (SOFA) score, the patients were divided into low SOFA score group (SOFA score ≤3) and high SOFA score group (SOFA score > 3). Venous blood was collected at the time of admission. The level of plasma Presepsin was detected by chemiluminescence enzyme-linked immunoassay. The level of plasma procalcitonin (PCT) was detected by enzyme-linked immunofluorescence method. The level of C-reactive protein (CRP) was detected by scattering turbidimetry. White blood cell count (WBC) and neutrophil count (NEUT) were measured by automatic blood cell analyzer. For patients with fear of cold or chills, venous blood of upper limbs was taken for blood culture at the time of admission. The differences in inflammatory biomarkers were compared between the two groups. Binary multivariate Logistic regression analysis was used to screen the early risk factors of sepsis in fever outpatients with suspected sepsis. Receiver operator characteristic curve (ROC curve) was drawn to investigate the early diagnostic value of Presepsin and other inflammatory markers in sepsis, and to analyze the optimal cut-off value. A total of 149 fever outpatients with suspected sepsis were enrolled, including 92 patients with low SOFA score and 57 patients with high SOFA score. Plasma PCT and Presepsin levels in the high SOFA score group were significantly higher than those in the low SOFA score group [PCT (μg/L): 0.77 (0.18, 2.02) vs. 0.22 (0.09, 0.71), Presepsin (ng/L): 1 129.00 (785.50, 1 766.50) vs. 563.00 (460.50, 772.25), both P < 0.01]. There was no significant difference in WBC, NEUT, CRP or positive rate of blood culture between the high and low SOFA score groups [WBC (×109/L): 11.32±5.47 vs. 11.14±5.29, NEUT (×109/L): 9.88±4.89 vs. 9.60±5.10, CRP (mg/L): 54.05 (15.95, 128.90) vs. 46.11 (19.60, 104.60), blood culture positivity rate: 42.3% (11/26) vs. 29.4% (10/34), all P > 0.05]. Multivariate Logistic regression analysis showed that Presepsin was an early risk factor for sepsis in suspected sepsis patients in fever clinics [odds ratio (OR) = 16.96, 95% confidence interval (95%CI) was 6.35-45.29, P = 0.000]. ROC curve analysis showed that the early diagnostic value of Presepsin in sepsis was significantly better than WBC, NEUT, CRP, PCT, and blood culture [the area under the ROC curve (AUC) and 95%CI: 0.832 (0.771-0.899) vs. 0.522 (0.424-0.619), 0.532 (0.435-0.629), 0.533 (0.435-0.632), 0.664 (0.574-0.753), 0.554 (0.458-0.650)]. When the optimal cut-off value of Presepsin was 646.50 ng/L, its sensitivity and positive predictive value were higher than those of WBC, NEUT, CRP, and PCT (sensitivity: 89.5% vs. 38.6%, 68.4%, 38.6%, 57.9%; positive predictive value: 64.6% vs. 44.9%, 44.3%, 47.8%, 55.9%). Plasma PCT and Presepsin have early diagnostic value for sepsis in suspected sepsis patients in fever clinics, and Presepsin is more sensitive than PCT and can be used as an early marker of sepsis.

RATIONALE. The Sequential Organ Failure Assessment (SOFA) score is a well-studied tool for quantifying organ dysfunction in critically-ill individuals, particularly those with sepsis. Higher SOFA scores have been associated with mortality among patients admitted to the intensive care unit. Given the absence of a gold standard, SOFA is often used in trauma studies for predicting risk of mortality but remains poorly validated. The present research aims to evaluate the utility of SOFA (both overall and organ-specific scores) for identifying individuals at highest risk of mortality following severe acute trauma. METHODS. The present study encompasses a subset of individuals enrolled in the Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study based out of the Western Cape region of South Africa for whom at least one SOFA score was obtained during resuscitation, damage control surgery, and/or while admitted to the intensive care unit. Both univariable and multivariable logistic regression were used to evaluate the relationship between both overall and organ-specific SOFA scores and 30-day mortality. Area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC) were used to assess performance characteristics of SOFA scores with respect to predicting 30-day mortality. RESULTS. Data were obtained from 2555 subjects enrolled in the EpiC study for whom one or more SOFA scores were calculated during the first 7 days following hospital admission. The median of the 7-day maximum SOFA score was 2 (range: 0-18). Mortality at 30 days occurred in 423 (17%) of subjects. Univariable regression demonstrated that for every one-point increase in SOFA score within the first 7 days of hospitalization, the odds of 30-day mortality increased by 59% (OR=1.59; 95%CI=1.52-1.67). Similar associations were observed for all six of the organ-specific SOFA scores in multivariable regression, with the strongest associations observed for the neurologic (2.16; 1.99-2.34), respiratory (2.05; 1.87-2.26), and cardiovascular (1.93; 1.78-2.08) sub-components. Overall SOFA score yielded an AUROC of 0.85 and AUPRC 0.60 for 30-day mortality, with neurologic (AUROC=0.78, AUPRC=0.55), respiratory (0.75, 0.47), and cardiovascular (0.70, 0.52) sub-components yielding similar test characteristics. CONCLUSIONS. Both total and organ-specific SOFA scores during the first 7 days of hospital admission following acute severe trauma were associated with 30-day mortality. Neurologic, respiratory, and cardiovascular dysfunction had the strongest associations with mortality. Further studies should consider the performance of SOFA relative to the other predictive scoring systems to help establish the gold-standard in the trauma critical care population.

The novel coronavirus disease, COVID-19, is caused by a SARS-COV-2 infection and manifested in some clinical forms from mild to critical disease. The Sequential Organ Failure Assessment (SOFA) score has been used to predict the clinical outcomes of patients admitted to intensive care units with multiple organ failures. This study aimed to analyse the cut-off of the SOFA score with the best accuracy in predicting mortality in severe and critical COVID-19 population, and compared the survival rate difference of the high and low SOFA score according to the cut-off with the best accuracy from our study. This retrospective observational study analysed all of the severe and critical COVID-19 patients admitted to DR.Soetomo Hospital, Surabaya, Indonesia, from June to September 2020. We excluded patients who had died less than 48 hours upon ICU admission and patients who were discharged against medical advice (DAMA). A total of 123 patients were eligible. SOFA score significantly predicted ICU mortality of COVID-19 patients with the Area-under-curve of 0.9 (p<0.001). The survival rate of patients with the SOFA score of ?7 was 90%, compared to patients with the SOFA score of >7 with a survival rate of 10%. Patients with SOFA score ? 7 had a significantly longer survival time during ICU care (HR=15.85, p<0.001). Our study proved that patients with higher SOFA scores had a significantly different survival outcome during the ICU stay, with the score cut-off of 7. This score cut-off could significantly discriminate ICU survival with high predictive values.

IntroductionThe Sequential Organ Failure Assessment (SOFA) score is a widely utilized clinical tool for evaluating the severity of organ failure in critically ill patients and assessing their condition and prognosis in the intensive care unit (ICU). Research has demonstrated that higher SOFA scores are associated with poorer outcomes in these patients. However, the predictive value of the SOFA score for acute kidney injury (AKI), a common complication of diabetic ketoacidosis (DKA), remains uncertain. Therefore, this study aims to investigate the relationship between SOFA scores and the incidence of AKI in patients with DKA.MethodsThe study population was divided into two groups based on the median SOFA score (Q1: SOFA ≤3; Q2: SOFA &amp;gt;3). The primary endpoint was the incidence of AKI in patients with DKA. Secondary endpoints included renal replacement therapy (RRT) utilization and in-hospital mortality. Kaplan–Meier survival analysis, Cox proportional hazards models, and logistic regression models were employed to assess the association between SOFA and therisk of AKI in patients with DKA.ResultsOverall, 626 patients with DKA were included in this study, of which 335 (53%) were male. Kaplan–Meier survival analysis included that patients with higher SOFA scores experienced significantly increased cumulative incidences of AKI, higher rates of RRT utilization, and elevated in-hospital mortality. Furthermore, after adjusting for confounding factors, logistic regression and Cox proportional hazards analyses confirmed that SOFA scores remained significantly associated with the incidence of AKI in patients with DKA.ConclusionsOur study indicates that a high SOFA score is an independent risk predictor for the occurrence of AKI, the utilization of RRT, and in-hospital mortality in patients with DKA. The sofa score can be utilized as a biomarker to assess the risk of AKI in this patient population.

BackgroundPatients with a Sequential Organ Failure Assessment (SOFA) score >7 on post-transplant day (POD) 7 have been reported to have a higher risk of short-term mortality after living donor liver transplant (LDLT). We sought to identify factors that were associated with early mortality in this high-risk population.Material/MethodsA total of 102 patients with a high SOFA score (>7) on POD 7 were enrolled, of which 72 (70.6%) were assigned to the survivor group, and the other 30 (29.4%) patients were assigned to the non-survivor group according to post-transplant 3-month results. Demographics, clinical data, operative parameters, and individual SOFA component scores were collected. Independent risk factors for 3-month mortality were identified by multivariate logistic regression analysis using backward elimination procedures.ResultsOf 102 high SOFA score patients, the 3-month mortality rate after LDLT in our study was 29.4%. Four independent risk factors were indicative for early death: graft-to-recipient weight ratio (GRWR) <0.8 (hazard ratio [HR]=3.00; 95% CI=1.05–8.09; P=0.041), longer warm ischemia time (HR=37.84; 95% CI=1.63–880.77; P=0.024), high liver component of the SOFA score, and cardiovascular component of the SOFA score (liver component: HR=10.39; 95% CI=1.77–60.89; P=0.009 and cardiovascular component: HR=13.34; 95% CI=2.22–80.12; P=0.005).ConclusionsIn conclusion, 3-month mortality among patients with high SOFA score on POD 7 is associated with multiple independent risk factors, including smaller GRWR, longer warm ischemia time, and higher category of liver and cardiovascular component of SOFA score. By recognizing high-risk patients earlier, the LDLT outcomes may be improved by timely intensive therapies.

This study aimed to evaluate the accuracy and prognostic value of the sequential organ failure assessment (SOFA) score combined with C-reactive protein (CRP) in patients with complicated infective endocarditis (IE). A total of 246 consecutive patients with complicated IE were included in the multicentric prospective observational study. These patients were divided into four groups depending on the SOFA score and CRP optimal cutoff values (≥5 points and ≥17.6 mg/L, respectively), which were determined using the receiver operating characteristic analysis: low SOFA and low CRP (n = 83), low SOFA and high CRP (n = 87), high SOFA and low CRP (n = 25), and high SOFA and high CRP (n = 51). The primary endpoint was in-hospital death, and the secondary endpoint was long-time mortality, defined as subsequent readmission and 3-years mortality in the follow-up period. High SOFA score and high CRP were associated with approximately 29.410% (15/51) of higher incidence of in-hospital death with an area under the curve of 0.872. Multivariate analyses showed that age [odds ratio (OR) = 2.242, 1.142–4.401], neurological failure (Glasgow Coma Scale ≤ 12) (OR = 2.513, 1.041–4.224), Staphylococcus aureus (OR = 2.151, 1.252–4.513), SOFA ≥ 5 (OR = 9.320, 3.621–16.847), and surgical treatment (OR = 0.121, 0.031–0.342) were clinical predictors for in-hospital death. On following up for 12–36 months, SOFA ≥ 5 (p = 0.000) showed higher mortality. A high SOFA score combined with increased CRP levels is associated with in-hospital mortality. Also, SOFA score, but not CRP, predicts long-term mortality in complicated IE.

552 Background: The EPIC deterioration index (EDI) and the Sequential Organ Failure Assessment (SOFA) scores are commonly used in practice. However, no studies have examined their performance in hospitalized cancer patients just before intensive care unit (ICU) transfer, a critical point to decide if ICU transfer would be appropriate. We examined the prognostic accuracy of the EDI and SOFA for 48 h ICU mortality. Methods: This study evaluated consecutive hospitalized medical oncology patients transferred to the ICU from January 1, 2021 to December 31, 2023. Univariable and multivariable logistic regression models examined if EDI scores immediately prior to ICU transfer (EDI-now) and SOFA scores immediately prior to ICU transfer were predictive of 48 h ICU mortality. We assessed the performance of EDI-now, EDI at 24 h before ICU transfer (EDI-24 h), the difference between EDI-24h and EDI-now (EDI-change) and the SOFA scores using the area under the receiver operating characteristic curve (AUROC). Results: There were 1987 hospitalizations amongst 1907 unique patients (mean age=61, male=58%); 236 (11.9%) who died within 48 h of ICU transfer. In the multivariable analysis, EDI-Now (OR [95% CI]; 3.11 [2.26,4.27], p&lt;0.0001) and SOFA (OR [95% CI]; 1.78 [1.31,2.43], p=0.0002) were significantly associated with 48 h ICU mortality. The AUROC for EDI-now, EDI-24 h, EDI-change and SOFA were 0.657, 0.563, 0.635, and 0.621, respectively. The optimal cut-off threshold for EDI-now was 54.7 with 73.7% sensitivity, 54.4% specificity, 17.9% positive predictive value (PPV) and 91.5% negative predictive value (NPV). The optimal cut-off threshold for SOFA score was 5 with 63.1% sensitivity, 53.6% specificity, 15.5% PPV and 91.5% NPV. Conclusions: EDI-now ≥ 55 and SOFA ≥ 5 were associated with greater 48-hour ICU mortality. High NPVs in our study suggest that clinicians could potentially use low EDI and SOFA scores to identify patients at lower risk of dying within 48 hours and perhaps more appropriate for ICU transfer. However, low PPVs indicate that high EDI and SOFA scores cannot be used to predict higher risk of 48-hour mortality prior to ICU transfer. Better prognostic scores are needed for the medical oncology population. Performance of EDI-now and SOFA with different cutoff points. EDI-Now Sensitivity Specificity PPV NPV Overall Accuracy Youden's J Statistic &gt;50 0.81 0.44 0.16 0.94 0.49 0.25 &gt;60 0.58 0.64 0.18 0.92 0.64 0.22 &gt;70 0.36 0.81 0.20 0.90 0.76 0.17 &gt;80 0.12 0.92 0.17 0.89 0.83 0.04 SOFA Sensitivity Specificity PPV NPV Overall Accuracy Youden's J Statistic &gt;4 0.80 0.36 0.14 0.93 0.42 0.16 &gt;6 0.50 0.66 0.17 0.91 0.64 0.16 &gt;8 0.25 0.85 0.19 0.89 0.78 0.11 &gt;10 0.09 0.96 0.26 0.89 0.86 0.06 Abbreviations: EDI: Epic Deterioration Index; NPV: Negative Predictive Value; PPV: Positive Predictive Value; SOFA: Sequential Organ Failure Assessment.

IntroductionVarious mortality predictive score models for coronavirus disease-2019 (COVID-19) have been deliberated. We studied how sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA), acute physiology and chronic health evaluation II (APACHE II), and new early warning signs (NEWS-2) scores estimate mortality in COVID-19 patients.Materials and methodsWe conducted a prospective cohort study of 53 patients with moderate-to-severe COVID-19. We calculated qSOFA, SOFA, APACHE II, and NEWS-2 on initial admission and re-evaluated on day 5. We performed logistic regression analysis to differentiate the predictors of qSOFA, SOFA, APACHE II, and NEWS-2 scores on mortality.ResultqSOFA, SOFA, APACHE II, and NEWS-2 scores on day 5 exhibited a difference between survivors and nonsurvivors (p <0.05), also between ICU and non-ICU admission (p <0.05). The initial NEWS-2 revealed a higher AUC value than the qSOFA, APACHE II, and SOFA score in estimating mortality (0.867; 0.83; 0.822; 0.794). In ICU, APACHE II score revealed a higher AUC value than the SOFA, NEWS-2, and qSOFA score (0.853; 0.832; 0.813; 0.809). Concurrently, evaluation on day 5 showed that qSOFA AUC had higher scores than the NEWS-2, APACHE II, and SOFA (0.979; 0.965; 0.939; 0.933) in predicting mortality, while SOFA and APACHE II AUC were higher in ICU admission than NEWS-2 and qSOFA (0.968; 0.964; 0.939; 0.934). According to the cutoff score, APACHE II on day 5 revealed the highest sensitivity and specificity in predicting the mortality (sensitivity 95.7%, specificity 86.7%).ConclusionAll scores signify good predictive values on COVID-19 patients mortality following the evaluation on the day 5. Nonetheless, APACHE-II appears to be the best at predicting mortality and ICU admission rate.How to cite this articleAsmarawati TP, Suryantoro SD, Rosyid AN, Marfiani E, Windradi C, Mahdi BA, et al. Predictive Value of Sequential Organ Failure Assessment, Quick Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and New Early Warning Signs Scores Estimate Mortality of COVID-19 Patients Requiring Intensive Care Unit. Indian J Crit Care Med 2022;26(4):464–471.