Risk assessment in sepsis: a new prognostication rule by APACHE II score and serum soluble urokinase plasminogen activator receptor

Evangelos J Giamarellos‐Bourboulis ,Anna Linnér,Vassiliki Mylona,Androniki Marioli,Ioanna Dimopoulou,Athina Savva,Christina Routsi,Konstantinos Mandragos,George Koratzanis,Iraklis Tsangaris,Carl-Johan Treutiger,Korina Lymberopoulou,Charalambos Gogos,Apostolos Armaganidis,Marina Koupetori,Michael Chrisofos,Ioannis Kritselis,George Adamis,Efterpi Apostolidou,Athanassios Prekates,Maria Mouktaroudi,Katerina Kotzampassi,Marianna Georgitsi,Ioannis Koutelidakis,Anastasia Antonopoulou,Anna Mega,Jonas Sundén-Cullberg,Chrysostomos Katsenos ,Anna Norrby‐Teglund ,Maria Rosario ,George Dimοpoulos

doi:10.1186/cc11463

Abstract

IntroductionEarly risk assessment is the mainstay of management of patients with sepsis. APACHE II is the gold standard prognostic stratification system. A prediction rule that aimed to improve prognostication by APACHE II with the application of serum suPAR (soluble urokinase plasminogen activator receptor) is developed.MethodsA prospective study cohort enrolled 1914 patients with sepsis including 62.2% with sepsis and 37.8% with severe sepsis/septic shock. Serum suPAR was measured in samples drawn after diagnosis by an enzyme-immunoabsorbent assay; in 367 patients sequential measurements were performed. After ROC analysis and multivariate logistic regression analysis a prediction rule for risk was developed. The rule was validated in a double-blind fashion by an independent confirmation cohort of 196 sepsis patients, predominantly severe sepsis/septic shock patients, from Sweden.ResultsSerum suPAR remained stable within survivors and non-survivors for 10 days. Regression analysis showed that APACHE II ≥17 and suPAR ≥12 ng/ml were independently associated with unfavorable outcome. Four strata of risk were identified: i) APACHE II <17 and suPAR <12 ng/ml with mortality 5.5%; ii) APACHE II < 17 and suPAR ≥12 ng/ml with mortality 17.4%; iii) APACHE II ≥ 17 and suPAR <12 ng/ml with mortality 37.4%; and iv) APACHE II ≥17 and suPAR ≥12 ng/ml with mortality 51.7%. This prediction rule was confirmed by the Swedish cohort.ConclusionsA novel prediction rule with four levels of risk in sepsis based on APACHE II score and serum suPAR is proposed. Prognostication by this rule is confirmed by an independent cohort.

Highlights

Risk assessment is the mainstay of management of patients with sepsis
Positive blood cultures for Escherichia coli were found in 113 patients (5.9%), for Klebsiella pneumoniae in 79 patients (4.1%), for Pseudomonas aeruginosa in 40 patients (2.1%), for Acinetobacter baumannii in 32 patients (1.7%), for other Gram-negative bacteria in 30 patients (1.5%), for Staphylococcus aureus in 21 patients (1.1%), and for Enterococcus spp in 15 patients (0.8%)
Positive quantitative urine cultures for E. coli were found in 262 patients (13.7%), for K. pneumoniae in 44 patients (2.3%), for P. aeruginosa in 40 patients (2.1%), for other Gram-negative bacteria in 62 patients (3.3%), and for Enterococcus spp in 29 patients (1.5%)

Summary

Introduction

Risk assessment is the mainstay of management of patients with sepsis. Severe sepsis and septic shock are among the leading causes of death worldwide. The mainstay in the proper management of sepsis is early recognition of the patient at high risk for death. This is traditionally based on the application of severity scores and serum biomarkers. In the case of young patients with severe sepsis but without chronic organ failures, the APACHE II score may be relatively low despite the risk of an unfavorable outcome. Older septic patients with chronic organ failures may provide high APACHE II scores even when the risk for dying from sepsis is low [2]

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