Sepsis-related Organ Failure Assessment Score Research Articles

Prevalence and Impact of Vitamin D Deficiency in Critically Ill Cancer Patients Admitted to the Intensive Care Unit.

Vitamin D deficiency is frequent in cancer patients and a risk factor for morbidity and mortality during critical illness. This single-center retrospective study analyzed 25-hydroxyvitamin D levels in critically ill cancer patients (n = 178; hematologic, n = 108; solid, n = 70) enrolled in a prospective ICU registry. The primary analysis was the prevalence of vitamin D deficiency (<20 ng/mL) and the severe deficiency (≤12 ng/mL). Secondary analyses included risk factors for vitamin D deficiency and its impact on ICU, hospital, and 1-year mortality. The prevalence of vitamin D deficiency and severe deficiency was 74% (95% CI: 67–80%) and 54% (95% CI: 47–61%). Younger age, relapsed/refractory disease, and a higher sepsis-related organ failure assessment (SOFA) score were independent risk factors for vitamin D deficiency (p < 0.05). After adjusting for relapsed/refractory disease, infection, the SOFA score, and the early need for life-supporting interventions, severe vitamin D deficiency was an independent predictor of hospital mortality (OR: 2.21, 95% CI: 1.03–4.72, p = 0.04) and 1-year mortality (OR: 3.40, 95% CI: 1.50–7.71, p < 0.01), but not of ICU mortality. Conclusion: Vitamin D deficiency is common in critically ill cancer patients requiring ICU admission, but its impact on short-term mortality in this group is uncertain. The observed association of severe vitamin D deficiency with the post-ICU outcome warrants clinical consideration and further study.

Correlation of Vitamin D Deficiency with Predictors of Mortality in Critically Ill Children at a Tertiary Care Centre in North India-A Prospective, Observational Study.

This study was conducted to assess the relationship of vitamin D deficiency (VDD) with various demographic characteristics, laboratory parameters, and predictors of mortality. This prospective observational study was performed at pediatric intensive care unit (PICU) of a tertiary care hospital situated in north India. A total of 125 children admitted in PICU with age from 2 months to 14 years were analyzed. The subjects were classified as Vitamin D deficient (≤20 ng/mL) and nondeficient (>20 ng/mL). The relationship between VDD and predictors of mortality were analyzed using correlation and multivariate analysis. Respiratory system (40%) was most commonly involved. VDD was seen in 72% of the patients. There was statistically significant correlation of VDD with age ( p = 0.019), season ( p = 0.018), height ( p = 0.005), and weight ( p = 0.003). On multivariate analysis factors associated with VDD were age (odds ratio [OR] = 1.01, 95% confidence interval [CI] 1.00-1.03, p = 0.006), season (OR = 3.98, 95% CI 1.09-14.50, p = 0.036). VDD was also correlated to bacteriuria ( p = 0.033), cardiovascular sequential sepsis-related organ failure assessment score (CV-SOFA score) ( p = 0.001), and mechanical ventilation ( p = 0.043). On multivariate analysis, factors associated with VDD were bacteriuria (OR = 4.88, 95% CI 1.04-22.89, p = 0.04), mechanical ventilation requirement (OR = 2.95, 95% CI 1.12-7.85, p = 0.029), and CV-SOFA score (OR = 2.33, 95% CI 1.14-4.76, p = 0.021). Median (interquartile range) duration of PICU stay in VDD patients was (3-7) days while in nondeficient patients it was (2-6) days ( p = 0.107). VDD was a significant risk factor for the need of mechanical ventilation, bacteriuria, and mortality among patients in our cohort.

Failure of Lactate Clearance Predicts the Outcome of Critically Ill Septic Patients.

Purpose: Early lactate clearance is an important parameter for prognosis assessment and therapy control in sepsis. Patients with a lactate clearance >0% might differ from patients with an inferior clearance in terms of intensive care management and outcomes. This study analyzes a large collective with regards to baseline risk distribution and outcomes. Methods: In total, 3299 patients were included in this analysis, consisting of 1528 (46%) ≤0% and 1771 (54%) >0% patients. The primary endpoint was intensive care unit (ICU) mortality. Multilevel logistic regression analyses were used to compare both groups: A baseline model (model 1) with lactate clearance as a fixed effect and ICU as a random effect was installed. For model 2, patient characteristics (model 2) were included. For model 3, intensive care treatment (mechanical ventilation and vasopressors) was added to the model. Models 1 and 2 were used to evaluate the primary and secondary outcomes, respectively. Model 3 was only used to evaluate the primary outcomes. Adjusted odds ratios (aORs) with respective 95% confidence intervals (CI) were calculated. Results: The cohorts had no relevant differences regarding the gender, BMI, age, heart rate, body temperature, and baseline lactate. Neither the primary infection focuses nor the ethnic background differed between both groups. In both groups, the most common infection sites were of pulmonary origin, the urinary tract, and the gastrointestinal tract. Patients with lactate clearance >0% evidenced lower sepsis-related organ failure assessment (SOFA) scores (7 ± 6 versus 9 ± 6; p < 0.001) and creatinine (1.53 ± 1.49 versus 1.80 ± 1.67; p < 0.001). The ICU mortality differed significantly (14% versus 32%), and remained this way after multivariable adjustment for patient characteristics and intensive care treatment (aOR 0.43 95% CI 0.36–0.53; p < 0.001). In the additional sensitivity analysis, the lack of lactate clearance was associated with a worse prognosis in each subgroup. Conclusion: In this large collective of septic patients, the 6 h lactate clearance is an independent method for outcome prediction.

Can capillary lactate improve early warning scores in emergency department? An observational, prospective, multicentre study.

To determine the prognostic usefulness of the National Early Warning Score-2 (NEWS2) and quick Sepsis-related Organ Failure Assessment (qSOFA) scores, in isolation and combined with capillary lactate (CL), using the new NEWS2-L and qSOFA-L scores to predict the 30-day mortality risk. Prospective, multicentre and observational study in patients across four EDs. We collected sets of vital signs and CL and subsequently calculated NEWS2, qSOFA, NEWS2-L and qSOFA-L scores when patients arrived at the ED. The main outcome measure was all-cause mortality 30days from the index event. A total of 941 patients were included. Thirty-six patients (3.8%) died within 30days of the index event. A high CL level has not been linked to a higher mortality. The NEWS2 presented AUROC of 0.72 (95% CI: 0.62-0.81), qSOFA of 0.66 (95% CI: 0.56-0.77) (P<.001 in both cases) and CL 0.55 (95% CI: 0.42-0.65; P=.229) to predict 30-day mortality. The addition of CL to the scores analysed does not improve the results of the scores used in isolation. NEWS2 and qSOFA scores are a very useful tool for assessing the status of patients who come to the ED in general for all types of patients in triage categories II and III and for detecting the 30-day mortality risk. CL determined systematically in the ED does not seem to provide information on the prognosis of the patients.

Assessment of Machine Learning to Estimate the Individual Treatment Effect of Corticosteroids in Septic Shock

The survival benefit of corticosteroids in septic shock remains uncertain. To estimate the individual treatment effect (ITE) of corticosteroids in adults with septic shock in intensive care units using machine learning and to evaluate the net benefit of corticosteroids when the decision to treat is based on the individual estimated absolute treatment effect. This cohort study used individual patient data from 4 trials on steroid supplementation in adults with septic shock as a training cohort to model the ITE using an ensemble machine learning approach. Data from a double-blinded, placebo-controlled randomized clinical trial comparing hydrocortisone with placebo were used for external validation. Data analysis was conducted from September 2019 to February 2020. Intravenous hydrocortisone 50 mg dose every 6 hours for 5 to 7 days with or without enteral 50 μg of fludrocortisone daily for 7 days. The control was either the placebo or usual care. All-cause 90-day mortality. A total of 2548 participants were included in the development cohort, with median (interquartile range [IQR]) age of 66 (55-76) years and 1656 (65.0%) men. The median (IQR) Simplified Acute Physiology Score (SAPS II) was 55 [42-69], and median (IQR) Sepsis-related Organ Failure Assessment score on day 1 was 11 (9-13). The crude pooled relative risk (RR) of death at 90 days was 0.89 (95% CI, 0.83 to 0.96) in favor of corticosteroids. According to the optimal individual model, the estimated median absolute risk reduction was of 2.90% (95% CI, 2.79% to 3.01%). In the external validation cohort of 75 patients, the area under the curve of the optimal individual model was 0.77 (95% CI, 0.59 to 0.92). For any number willing to treat (NWT; defined as the acceptable number of people to treat to avoid 1 additional outcome considering the risk of harm associated with the treatment) less than 25, the net benefit of treating all patients vs treating nobody was negative. When the NWT was 25, the net benefit was 0.01 for the treat all with hydrocortisone strategy, -0.01 for treat all with hydrocortisone and fludrocortisone strategy, 0.06 for the treat by SAPS II strategy, and 0.31 for the treat by optimal individual model strategy. The net benefit of the SAPS II and the optimal individual model treatment strategies converged to zero for a smaller number willing to treat, but the individual model was consistently superior than model based on the SAPS II score. These findings suggest that an individualized treatment strategy to decide which patient with septic shock to treat with corticosteroids yielded positive net benefit regardless of potential corticosteroid-associated side effects.

Diverticular Disease of the Appendix Is Associated with Complicated Appendicitis

Introduction: Diverticular disease of the vermiform appendix (DDA) has an incidence of 0.004 to 2.1% in appendicectomy specimens. DDA is variably associated with perforation and malignancy. We report a single-center experience of DDA. The primary aim is to validate the association of DDA with complicated appendicitis or malignancy, and the secondary aim is to validate systemic inflammatory response syndrome (SIRS) criteria and quick Sepsis-related Organ Failure Assessment (qSOFA) scores. Methods: The histopathology reports of 2,305 appendicectomy specimens from January 2011 to December 2015 were reviewed. Acute appendicitis was found in 2,164 (93.9%) specimens. Histology of the remaining 141 (6.1%) patients revealed: normal appendix (n = 110), DDA (n = 22), endometriosis of appendix (n = 6), and an absent appendix (n = 3). Patient demographics, clinical profile, operative data, and perioperative outcomes of DDA patients are studied. Modified Alvarado score, Andersson score, SIRS criteria, and qSOFA scores were retrospectively calculated. Results: The incidence of DDA was 0.95%. Ten patients (45.5%) had diverticulitis. The mean age of DDA patients was 39.5 years (range 23–87), with male preponderance (n = 12, 54.5%). The median Modified Alvarado score was 8 (range 4–9), and the median Andersson score was 5 (range 2–8). Fourteen patients (63.6%) had SIRS, and none had a high qSOFA score. Eight patients (36.4%) had complicated appendicitis (perforation [n = 2] or abscess [n = 6]). Eleven (50%) patients underwent laparoscopic appendicectomy. There were three 30-day readmissions and no mortality. Conclusion: DDA is a distinct clinical pathology associated with complicated appendicitis.

Epidemiology and Outcomes of Acute Kidney Injury in COVID-19 Patients with Acute Respiratory Distress Syndrome: A Multicenter Retrospective Study

Background: Acute kidney injury (AKI) is associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). However, the epidemiological features and outcomes of AKI among COVID-19 patients with ARDS are unknown. Methods: We retrospectively recruited consecutive adult COVID-19 patients who were diagnosed with ARDS according to Berlin definition from 13 designated intensive care units in the city of Wuhan, China. Potential risk factors of AKI as well as the relation between AKI and in-hospital mortality were investigated. Results: A total of 275 COVID-19 patients with ARDS were included in the study, and 49.5% of them developed AKI during their hospital stay. In comparison with patients without AKI, patients who developed AKI were older, tended to have chronic kidney disease, had higher Sepsis-Related Organ Failure Assessment score on day 1, and were more likely to receive invasive ventilation and develop acute organ dysfunction. Multivariate analysis showed that age, history of chronic kidney disease, neutrophil-to-lymphocyte ratio, and albumin level were independently associated with the occurrence of AKI. Importantly, increasing AKI severity was associated with increased in-hospital mortality when adjusted for other potential variables: odds ratio of stage 1 = 5.374 (95% CI: 2.147–13.452; p < 0.001), stage 2 = 6.216 (95% CI: 2.011–19.210; p = 0.002), and stage 3 = 34.033 (95% CI: 9.723–119.129; p < 0.001). Conclusion: In this multicenter retrospective study, we found that nearly half of COVID-19 patients with ARDS experienced AKI during their hospital stay. The coexistence of AKI significantly increased the mortality of these patients.

Utility of established prognostic scores in COVID-19 hospital admissions: multicentre prospective evaluation of CURB-65, NEWS2 and qSOFA

IntroductionThe COVID-19 pandemic is ongoing, yet, due to the lack of a COVID-19-specific tool, clinicians must use pre-existing illness severity scores for initial prognostication. However, the validity of such scores...

Diagnostic and Prognostic Utility Compared Among Different Sepsis Scoring Systems in Adult Patients With Sepsis in Thailand: A Prospective Cohort Study.

BackgroundThe diagnostic and prognostic utility of various sepsis scores varied among different cohorts and settings.MethodsA prospective cohort study in adult patients with sepsis at Siriraj Hospital (Bangkok, Thailand) was conducted during January to July 2019. The performance of sepsis assessments, including systemic inflammatory response syndrome (SIRS) score, sequential organ failure assessment (SOFA) score, quick sepsis-related organ failure assessment (qSOFA) score, modified early warning score (MEWS), and national early warning score (NEWS), for sepsis detection and mortality prediction were compared with agreement between 2 infectious disease (ID) specialists to determine their sepsis and septic shock status as the reference standard.ResultsAmong the 470 subjects included in this study, 206 patients (43.8%) were determined by 2 ID specialists to have sepsis. Systemic inflammatory response syndrome ≥2, qSOFA ≥2, and NEWS ≥5 yielded the highest sensitivity (93.2%), specificity (81.3%), and accuracy (72.6%), respectively, for detecting sepsis. The SIRS ≥2 had the highest sensitivity (97.8%), whereas qSOFA ≥2 had the highest specificity (61%) and accuracy (69.7%) for predicting mortality among sepsis patients. Receiver operating characteristic (ROC) curve showed MEWS to have the highest discriminatory power for sepsis detection (area under the ROC curve [AUROC], 0.79; 95% confidence interval [CI], 0.74–0.83), whereas SOFA had the highest discriminatory power for predicting hospital mortality (AUROC, 0.76; 95% CI, 0.69–0.79).ConclusionsThe NEWS ≥5 and qSOFA ≥2 were the most accurate scoring systems for sepsis detection and mortality prediction, respectively. Each scoring system is useful for different specific purposes relative to early detection and mortality prediction in sepsis patients.

Camostat Mesylate May Reduce Severity of Coronavirus Disease 2019 Sepsis: A First Observation.

Objectives:Severe acute respiratory syndrome coronavirus 2 cell entry depends on angiotensin-converting enzyme 2 and transmembrane serine protease 2 and is blocked in cell culture by camostat mesylate, a clinically proven protease inhibitor. Whether camostat mesylate is able to lower disease burden in coronavirus disease 2019 sepsis is currently unknown.Design:Retrospective observational case series.Setting:Patient treated in ICU of University hospital Göttingen, Germany.Patients:Eleven critical ill coronavirus disease 2019 patients with organ failure were treated in ICU.Interventions:Compassionate use of camostat mesylate (six patients, camostat group) or hydroxychloroquine (five patients, hydroxychloroquine group).Measurements and Main Results:Clinical courses were assessed by Sepsis-related Organ Failure Assessment score at days 1, 3, and 8. Further, viral load, oxygenation, and inflammatory markers were determined. Sepsis-related Organ Failure Assessment score was comparable between camostat and hydroxychloroquine groups upon ICU admission. During observation, the Sepsis-related Organ Failure Assessment score decreased in the camostat group but remained elevated in the hydroxychloroquine group. The decline in disease severity in camostat mesylate treated patients was paralleled by a decline in inflammatory markers and improvement of oxygenation.Conclusions:The severity of coronavirus disease 2019 decreased upon camostat mesylate treatment within a period of 8 days and a similar effect was not observed in patients receiving hydroxychloroquine. Camostat mesylate thus warrants further evaluation within randomized clinical trials.

Pediatric SOFA score for detecting sepsis in children

Background The pediatric logistic organ dysfunction-2 (PELOD-2) score is recommended by the Indonesian Pediatric Society Emergency and Intensive Care Working Group as an indicator of life-threatening organ dysfunction for sepsis in children. However, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) recommended the Sequential (Sepsis-related) Organ Failure Assessment (SOFA) score in determining life-threatening organ dysfunction, which has not been adjusted for pediatric patients.&#x0D; Objective To assess the accuracy of the pediatric SOFA score in diagnosing sepsis in children admitted to the pediatric intensive care unit (PICU) at Mohammad Hoesin Hospital, Palembang, South Sumatera.&#x0D; Methods The study was conducted in children with organ dysfunction caused by infection admitted in PICU, from April to December 2019. Subjects were included by consecutive sampling, according to the following inclusion criteria: all patients aged 1 month to 18 years who met organ dysfunction and two SIRS criteria, with infection according to the 2005 PSCC criteria. Laboratory tests performed included complete blood count (CBC), blood gas analysis, measurement of C-reactive protein (CRP), liver and kidney function tests. In all patients, pSOFA and PELOD-2 scores were calculated within 24 hours of admission. We compared the accuracy of pSOFA score to PELOD-2 score ≥ 11. &#x0D; Results Of 108 subjects, there were 59 males and 49 females, with median age 11 (range 1-193) months. We compared the accuracy of pSOFA score to PELOD-2 score ≥ 11 and obtained a sensitivity of 93.3% and a specificity of 79.5%, for pSOFA cut-off score ≥ 8. Pediatric SOFA score cutoff ≥ 8 was determined by receiver operating curve (ROC). The area under the curve (AUC) for pediatric SOFA score was 93.9% (95%CI 89.7 to 98.0%).&#x0D; Conclusion Pediatric SOFA score ≥ 8 is the optimal cut-off for predicting life-threatening organ dysfunction in pediatric sepsis. Multicenter revalidation is needed to find the most optimal cut-off point for general use in Indonesia.

Early use of high-dose vitamin C is beneficial in treatment of sepsis.

Vitamin C has shown benefits in patients with sepsis in addition to standard therapy recently. However, further evidence is required to verify the efficacy of vitamin C in clinical practice. This study aimed to investigate the effect of adjunctive intravenous high-dose vitamin C treatment on hospital mortality in patients with sepsis. One hundred seventeen patients with sepsis in our department from June 2017 to May 2019 were randomly divided into two groups: the control group (56 cases) and the vitamin C group (61 cases). The control group was treated by the routine and basic therapy with intravenous drip of 5% dextrose and placebo (100ml/time, 2 times/day), while the vitamin C group was administered intravenously by 3.0g vitamin C dissolved into 5% dextrose (100ml/time, 2 times/day) based on the control group. The mortality and efficacy were statistically analyzed and compared between the two groups. The 28-day mortality differed significantly between the control group and the vitamin C group (42.97% vs. 27.93%) (p < 0.05). The changes in the sepsis-related organ failure assessment (ΔSOFA) scores at 72h after ICU admission (4.2 vs. 2.1), the application time of vasoactive drugs (25.6 vs. 43.8), and the procalcitonin clearance (79.6% vs. 61.3%) differed significantly between groups (p < 0.05). The early treatment of sepsis with intravenous high-dose vitamin C in combination with standard therapy showed a beneficial effect on sepsis, in terms of the reduced 28-day mortality, the decreased SOFA score, and the increased clearance rate of procalcitonin.

Epidemiology, clinical characteristics, and outcome of candidemia in critically ill patients in Germany: a single-center retrospective 10-year analysis

BackgroundDespite advances in the management of bloodstream infections (BSI) caused by Candida spp., the mortality still remains high in critically ill patients. The worldwide epidemiology of yeast-related BSI is subject to changing species distribution and resistance patterns, challenging antifungal treatment strategies. The aim of this single-center study was to identify predictors of mortality after 28 and 180 days in a cohort of mixed surgical and medical critically ill patients with candidemia.MethodsPatients, who had been treated for laboratory-confirmed BSI caused by Candida spp. in one of 12 intensive care units (ICU) at a University hospital between 2008 and 2017, were retrospectively identified. We retrieved data including clinical characteristics, Candida species distribution, and antifungal management from electronic health records to identify risk factors for mortality at 28 and 180 days using a Cox regression model.ResultsA total of 391 patients had blood cultures positive for Candida spp. (incidence 4.8/1000 ICU admissions). The mortality rate after 28 days was 47% (n = 185) and increased to 60% (n = 234) after 180 days. Age (HR 1.02 [95% CI 1.01–1.03]), a history of liver cirrhosis (HR 1.54 [95% CI 1.07–2.20]), septic shock (HR 2.41 [95% CI 1.73–3.37]), the Sepsis-related Organ Failure Assessment score (HR 1.12 [95% CI 1.07–1.17]), Candida score (HR 1.25 [95% CI 1.11–1.40]), and the length of ICU stay at culture positivity (HR 1.01 [95% CI 1.00–1.01]) were significant risk factors for death at 180 days. Patients, who had abdominal surgery (HR 0.66 [95% CI 0.48–0.91]) and patients, who received adequate (HR 0.36 [95% CI 0.24–0.52]) or non-adequate (HR 0.31 [95% CI 0.16–0.62]) antifungal treatment, had a reduced mortality risk compared to medical admission and no antifungal treatment, respectively.ConclusionsThe mortality of critically ill patients with Candida BSI is high and is mainly determined by disease severity, multiorgan dysfunction, and antifungal management rather than species distribution and susceptibility. Our results underline the importance of timely treatment of candidemia. However, controversies remain on the optimal definition of adequate antifungal management.

Impact of Blood Type O on Mortality of Sepsis Patients: A Multicenter Retrospective Observational Study.

ABO blood groups have been implicated as potential risk factors for various diseases. However, no study has investigated the association between sepsis mortality and ABO blood types. We aimed to evaluate the impact of these blood types on mortality in patients with sepsis and septic shock. This retrospective observational study was conducted at two general hospitals in Japan. Patients diagnosed with sepsis or septic shock were included and divided into four groups based on blood type (O, A, B, and AB). The association between type O vs. other types and 28- and 90-day mortalities was evaluated using multivariate logistic regression analysis adjusted for age, sex, and Sequential (Sepsis-related) Organ Failure Assessment score. This study included 415 patients, of whom 131 (31.6%), 171 (41.2%), 81 (19.5%), and 32 (7.7%) had type O, A, B, and AB, respectively. Blood type O was not associated with 28-day (odds ratio: 1.7 p = 0.08) or 90-day mortality (odds ratio: 1.53, p = 0.091). However, type O was significantly associated with higher 90-day mortality (odds ratio: 3.26, p = 0.009) in patients with septic shock. The role of ABO blood type in risk stratification for septic shock and the mechanisms that potentially affect the prognosis of sepsis patients need further investigation.

Validation of the qSOFA score compared to the CRB-65 score for risk prediction in community-acquired pneumonia

ObjectiveThe qSOFA (quick sepsis-related organ failure assessment) score shows similarities to the CRB-65 pneumonia score, but its prognostic accuracy in patients with community-acquired pneumonia (CAP) has not been extensively evaluated. Our aim was to validate the qSOFA (-65) score in a large cohort of CAP patients. MethodsWe conducted a retrospective population-based cohort study including all CAP cases hospitalized between 1st January 2014 and 31st December 2018 from the German nationwide mandatory quality assurance programme. We excluded cases transferred from another hospital, with mechanical ventilation present on admission, and without documented respiratory rate. Predefined outcomes were hospital mortality and need for mechanical ventilation. ResultsAmong the 1,262,250 included cases, hospital mortality was 12.4% and the mechanical ventilation rate was 7.1%. All CRB and qSOFA criteria were associated with both outcomes, but the qSOFA had inferior sensitivity compared to the CRB-65 for mortality prediction. Including the age criterion ≥65 years, qSOFA-65 and CRB-65 performed similarly (AUC 0.69, 95%CI 0.69–0.69 versus 0.68, 95%CI 0.68–0.68). A qSOFA-65 of 0 was associated with fewer missed deaths (3328, 2.0%) compared to a CRB-65 of 0 (5480, 2.4%). The sensitivity of the suggested qSOFA cut-off of ≥2 for sepsis was low (mortality 25.8%, 95%CI 25.6–26.0%; mechanical ventilation 24.1%, 95%CI 23.8–24.4%). Results were similar when frail and palliative patients were excluded. ConclusionsThe qSOFA parameters show prognostic accuracy similar to the CRB parameters in CAP, but the sepsis cut-off of ≥2 lacked sensitivity. For sensitive mortality prediction, the age criterion ≥65 years should be added to the qSOFA.

How could we suspect life-threatening perinatal group A streptococcal infection?

AimPerinatal group A streptococcal infection is a rare but life‐threatening condition. Few reports have focused on its clinical characteristics and how to prevent deterioration. We report our experience with two antenatal fatal cases and reviewed 96 cases in the literature to assess the clinical characteristics of group A streptococcal infection.MethodsEnglish‐language clinical reports of antenatal and postnatal group A streptococcal infection in 1974–2019 were retrieved and examined. Relationships between clinical characteristics and maternal outcomes were assessed.ResultsUnivariate analysis revealed that antenatal group A streptococcal infection was significantly associated with an age of ≤19 or ≥ 35 years, cesarean section, sore throat as an initial symptom, positive throat culture, maternal death and fetal death. Multivariate analysis revealed that antenatal onset (odds ratio = 7.922, 95% confidence interval = 1.297–48.374; P = 0.025) and a quick sepsis‐related organ‐failure assessment score (qSOFA; low blood pressure, high respiratory rate or altered mental status) of ≥2 (odds ratio = 6.166, 95% confidence interval = 1.066–35.670; P = 0.042) were significantly related to maternal death.ConclusionPer our findings, antenatal group A streptococcal infection was significantly associated with maternal and fetal death. Further, the antenatal infection was revealed as a more critical risk factor. We suggest that the presence of any sign related to the qSOFA is a potential clue suspecting perinatal group A streptococcal infection in primary obstetric facilities.

Hypochloraemia is associated with 28-day mortality in patients with septic shock: a retrospective analysis of a multicentre prospective registry

ObjectivesHyperchloraemia is associated with poor clinical outcomes in sepsis patients; however, this association is not well studied for hypochloraemia. We investigated the prevalence of chloride imbalance and the association between...

Prognostic factors in older patients admitted in ICU with diagnosis of abdominal sepsis (sepsis-3 criteria)

Background & aims. In septic older patients, hospitalization in Intensive Care Unit (ICU) is often associated with unfavourable outcomes. The aim of this study was to estimate the prevalence of geriatric age in patients admitted to ICU for abdominal sepsis and to investigate predictors of mortality, including quickSOFA, a recent prognostic index proposed for septic patients. Methods. Prospective observational study on patients admitted to ICU of St. Anna Hospital (Ferrara) between January and July 2016 with the following inclusion criteria: 1) adults (18 years); 2) abdominal infection treated with surgically techniques; 3) admission to ICU. Demographic, clinical data and survival at 30 and 90-day were collected for each patient. Results. Thirty patients were enrolled, and the majority of geriatric patients (80% ≥ 65 years and 53% ≥ 75 years). The 30 and 90-day mortality was 17 and 37%, respectively. Almost all deaths occurred in older age (mortality rate of 42%). SOFA (Sepsis Related Organ Failure Assessment) score was the prognostic index most frequently associated with exitus at 30 (AUC = 0.702) and 90 days (AUC = 0.730). quickSOFA was only related to early mortality (AUC = 0.640). Conclusions. Our data confirm the high geriatric prevalence among patients admitted to ICU for abdominal sepsis, underlining the advanced age as a negative prognostic factor. SOFA score appears a reliable prognostic indicator of mortality, also in older population, while quickSOFA proved effective only for short-term mortality.

Early lactate measurements for predicting in-hospital mortality in paediatric sepsis.

We compared the performance of plasma lactate with high-sensitivity C-reactive protein (hs-CRP), and paediatric sepsis-related organ failure assessment (pSOFA) score for predicting mortality in septic children. Serial plasma lactate and hs-CRP levels and pSOFA score was assessed during early hospital stay in septic children. Out of 149 participants, 45 died. Plasma lactate at 0 h and 6 h was significantly higher, and lactate clearance was significantly lower in non-survivors. The optimal cut-off of plasma lactate at 6h for identifying mortality was 2.5 mmol/L (sensitivity 85% and specificity 74%). pSOFA score had the best predictive ability for mortality (AUC 0.89) followed by hs-CRP at 0 h (AUC 0.86), hs-CRP at 48 h (AUC 0.83), plasma lactate levels at 6 h (AUC 0.83), and plasma lactate at 0 h (AUC 0.67). pSOFA score, hs-CRP and hyperlactemia at 6 h can identify septic children at risk of dying.

Camostat Mesylate but Not Hydroxychloroquine May Reduce Severity of Organ Failure in COVID-19 Sepsis: A Case-Control Study

Background: The pandemic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease 2019 (COVID-19). COVID-19 may take a severe course, resulting in sepsis, and antivirals are urgently needed to combat the disease. However, at present, only drugs developed against other diseases are available including the Malaria drug hydroxychloroquine but their therapeutic efficacy is unclear. Camostat mesylate, a clinically-proven protease inhibitor for treatment of pancreatitis, was shown to block SARS-CoV-2 entry into lung cells. Whether camostat mesylate dampens COVID-19 induced sepsis and the associated organ failure is unknown. Here we compare clinical courses of critically ill COVID-19 patients treated with either camostat mesylate or hydroxychloroquine. Methods: Eleven COVID-19 patients with organ failure were treated in intensive care unit (ICU) at our institution. Five patients (group 1) received hydroxychloroquine and six patients (group 2) camostat mesylate. Clinical disease status was assessed by Simplified Acute Physiology Score (SAPS) II and Sequential/ Sepsis-related Organ Failure Assessment (SOFA) score at day 1, 3 and 8. Viral load was determined from nasopharyngeal swabs. Findings: Patient age ranged from 45 to 76 years, all but one had histories of chronic disease and cardiovascular risk factors. Median symptomatic period was 2-10 days before being transferred to ICU. No differences in SAPS II scores or SOFA scores were observed upon ICU admission. In group 1, SOFA and SAPS II scores remained elevated (2 patients died) while in group 2 SOFA and SAPS II score decreased from 9 to 4 points (1 patient died). The decline in disease severity for group 2 was paralleled by a decline in inflammatory markers, which was not observed in group 1. The virus load in the nasopharynx was variable between patients, did not correlate with organ failure and no marked differences were observed between groups 1 and 2. Interpretation: The severity of COVID-19 sepsis markedly decreased upon camostat mesylate treatment within a period of 8 days and a similar effect was not observed upon hydroxychloroquine treatment. Camostat mesylate thus warrants further evaluation within randomized clinical studies. Funding Statement: Authors were employed at the University of Gottingen or at the Infection Biology Unit of the German Primate Center (Leibniz Institute for Primate Research). All expenses were covered by publicly funded institutions. Stefan Pohlmann received funding from the German Federal Ministry of Education and Research (BMBF), RAPID Fund (#01KI1723D). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Compassionate use was approved by our local ethical committee at the University of Gottingen.