SIRS Criteria Research Articles

Utility of neutrophil CD64 in distinguishing bacterial infection from inflammation in severe alcoholic hepatitis fulfilling SIRS criteria

To assess utility of neutrophilCD64 (nCD64) expression in differentiating bacterial infection from inflammation in patients with severe alcoholic hepatitis (SAH) fulfilling systemic inflammatory response syndrome criteria. Patients with SAH and infection (n = 58), SAH without infection (n = 70), and healthy controls (n = 20) were included. Neutrophil CD64 expression by flowcytometry, serum Procalcitonin (ELISA) and C-reactive protein (Nephelometry) and neutrophil–lymphocyte ratio (NLR) were studied. Percentage of neutrophils with CD64 expression (nCD64%) was significantly higher in patients with SAH and infection than in those without infection and controls [76.2% (56.9–86.5) vs. 16% (12.6–23.1) vs. 7.05% (1.4–9.5), p < 0.05], as was their mean fluorescence intensity [MFI; 1431 (229–1828) vs. 853 (20–968) vs. 99.5 (54.7–140.7), p < 0.05]. Using a cut-off of 27%, the sensitivity and specificity of nCD64% to diagnose bacterial infection was 94% and 81%, respectively, with area under curve (AUC) of 0.95. At a cut-off value of 0.261 ng/ml, the sensitivity and specificity of serum procalcitonin was 83% and 72%, respectively, with AUC of 0.86. Serum CRP, total leukocyte count, NLR had AUCs of 0.78, 0.63 and 0.64, respectively. Quantitative measurement of nCD64 can better distinguish systemic bacterial infection and inflammation in SAH as compared to traditional biomarkers.

COMPARISON OF SIRS CRITERIA, QSOFA SCORE, AND A COMBINATION OF BOTH FOR THE DIAGNOSIS OF SEPSIS AND PREDICTION OF MORTALITY IN HOSPITALIZED ADULT PATIENTS WITH COVID-19

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Sepsis is common in critically ill COVID-19 patients and is associated with high mortality. However, the diagnosis of sepsis and the prediction of mortality are challenging in COVID-19 patients, especially in the early stage of sepsis. Research about the performance of SIRS criteria and qSOFA score in patients with COVID sepsis is limited. Therefore, this study aimed to compare the performance of SIRS, qSOFA, and a combination of both in hospitalized COVID-19 adult patients regarding the diagnosis of sepsis and the prediction of in-hospital mortality. METHODS: Retrospective data analysis included 341 patients who were hospitalized with laboratory-confirmed COVID-19 infection during April 2020 and January 2021 (the peaks of the first and second waves in New York state) at a 242-bed university-affiliated community-based hospital. Data from the initial patient encounter at the emergency room was collected by reviewing the electronic health records. SIRS criteria, qSOFA score, and a combination of both (SIRS+qSOFA) were analyzed by the MATLAB software. SIRS+qSOFA includes 5 parameters: tachypnea (respiratory rate ≥ 22), tachycardia (heart rate >90/min), fever or hypothermia (temperature >38°C (100.4°F) or 12000/mm³, 10% bands), altered mentation, and hypotension (systolic blood pressure ≤100 mmHg). The area under the receiver operating characteristic curves (AUC) was calculated to evaluate the performance of SIRS, qSOFA, and SIRS+qSOFA. RESULTS: In 341 COVID-19 patients, 128 patients were diagnosed with sepsis (37.5%), which included 77 expired patients (60.2%);213 patients were not diagnosed with sepsis (62.5%), which included 50 expired patients (23.5%). The AUCs for the diagnosis of sepsis with SIRS, qSOFA, and SIRS+qSOFA were 0.739, 0.731, and 0.793, respectively. The AUCs for the prediction of mortality with SIRS, qSOFA, and SIRS+qSOFA were 0.593, 0.665, and 0.646, respectively. For diagnosing sepsis, the sensitivity of SIRS (≥ 2), qSOFA (≥ 2), and SIRS+qSOFA (≥ 3) were 82.0%, 48.4%, and 68.8%, respectively;the specificity of SIRS (≥ 2), qSOFA (≥ 2), and SIRS+qSOFA (≥ 3) were 54.9%, 85.4%, and 76.5%, respectively. For predicting mortality, the sensitivity of SIRS (≥ 2), qSOFA (≥ 2), and SIRS+qSOFA (≥ 3) were 68.5%, 42.5%, and 55.9%, respectively;the specificity of SIRS (≥ 2), qSOFA (≥ 2), and SIRS+qSOFA (≥ 3) were 46.7%, 81.8%, and 68.7%, respectively. CONCLUSIONS: For diagnosing sepsis in COVID-19 patients, the performance of SIRS+qSOFA with 5 parameters (AUC=0.793) is better than either SIRS (AUC=0.739) or qSOFA (AUC=0.731). For predicting mortality, the performance of qSOFA (AUC=0.665) is superior to either SIRS (AUC=0.593) or SIRS+qSOFA (AUC=0.646). CLINICAL IMPLICATIONS: This study will facilitate the diagnosis of sepsis and the prediction of mortality in the hospitalized COVID-19 adult patients. DISCLOSURES: No relevant relationships by Shraddha Acharya, source=Web Response No relevant relationships by Inigo Atienza, source=Web Response No relevant relationships by Stephen Jesmajian, source=Web Response No relevant relationships by Jeffrey Lederman, source=Web Response No relevant relationships by Liyun Liu, source=Web Response No relevant relationships by Junfeng Xue, source=Web Response

BURKITT LYMPHOMA MIMICKING SEPTIC SHOCK: AN UNUSUAL PRESENTATION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Burkitt lymphoma (BL) is a highly aggressive non-Hodgkin B-cell lymphoma that typically presents with multiple metabolic derangements, kidney failure, involvement of the jaw or other facial bones, and enlarged lymph nodes. Our case report describes an initial presentation of (BL) with septic shock. CASE PRESENTATION: 25-year-old Caucasian female presented with a 4-day history of sharp non-radiating right upper quadrant abdominal pain, poor appetite, nausea, multiple episodes of loose watery stools, and polydipsia. Exam was notable for 2/4 SIRS criteria, with heart rate 134 and respiratory rate 29, and right upper quadrant was tender to palpation. Workup revealed white blood cell count 10.3 thou/uL, lactate 4.5 mmol/L, total bilirubin 1.5 mg/dL with direct bilirubin 0.8 mg/dL, AST 138 U/L, ALT 177 U/L, and alkaline phosphatase 601 U/L. Despite a 30cc/kg fluid bolus for resuscitation, lactate worsened to 5.2 mmol/L. With concern for septic shock, the patient was started on broad-spectrum antibiotics and admitted to the hospital with an intra-abdominal source suspected. Computed Tomography (CT) scan of the abdomen and pelvis with contrast demonstrated numerous hypoenhancing lesions of the liver (up to 80% of parenchyma), spleen, right kidney, and right adrenal gland. Blood cultures remained negative, with antibiotics discontinued after 48 hours, and lactate clearing with further fluid resuscitation. The patient underwent biopsy of the liver, which revealed findings consistent with Burkitt lymphoma (CD10, 19, 20 + on flow cytometry; Myc+, bcl2 and 6 – on FISH. PAX5, BCL6, and CD10 + and bcl2 - on immunochemistry). With improvement in symptoms, the patient was discharged with oncology follow-up. DISCUSSION: BL is a rare, but very aggressive, B-cell non-Hodgkin lymphoma, often associated with Ebstein Barr virus, human immunodeficiency virus, and overexpression of oncogene C-MYC on chromosome 8. It presents in three definite forms: endemic, sporadic, immunodeficiency-associated[4]. The sporadic variant is more common among caucasians[3] and in patients below 35 years of age with a median age at diagnosis of 30 years[1,2]. Patients usually present with abdominal signs and symptoms involving the small and large intestine mimicking acute appendicitis or intussusception. Excisional biopsy is preferred for the diagnosis of BL, with confirmation done by immunohistochemistry and cytogenetics. While aggressive, it is highly curable with a two-year survival rate of 80-90%, treatment consisting of multi-agent regimens. CONCLUSIONS: Clinicians, especially intensivists, should be aware of the numerous clinical conditions, such as Burkitt Lymphoma, which may mimic sepsis and septic shock as early diagnosis can improve outcomes and decrease overuse of antibiotics. Diagnosing Burkitt Lymphoma early can also improve patients' mortality with the initiation of early treatment to optimize survival. REFERENCE #1: World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues, Swerdlow SH, Campo E, Harris NL, et al. (Eds), IARC Press, Lyon 2008. REFERENCE #2: Armitage JO, Weisenburger DD ., New approach to classifying non-Hodgkin's lymphomas: clinical features of the major histologic subtypes. Non-Hodgkin's Lymphoma Classification Project., J Clin Oncol. 1998;16(8):2780. REFERENCE #3: Morton LM, Wang SS, Devesa SS, Hartge P, Weisenburger DD, Linet MS., Lymphoma incidence patterns by WHO subtype in the United States, 1992-200., Blood. 2006;107(1):265. Epub 2005 Sep 8. DISCLOSURES: No relevant relationships by Bohdan Baralo, source=Web Response No relevant relationships by Shambo Guha Roy, source=Web Response No relevant relationships by SANA MULLA, source=Web Response No relevant relationships by Ruqqiya Mustaqeem, source=Web Response No relevant relationships by Monisha Panda, source=Web Response No relevant relationships by Mahati Paravathaneni, source=Web Response No relevant relationships by Rajesh Thirumaran, source=Web Response No relevant relationships by Vihitha Thota, source=Web Response

HYPERGLYCEMIC CRISIS AND COVID-19 AT CROSSROADS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Diabetic Ketoacidosis (DKA) & Hyperosmolar Hyperglycemic State (HHS) are known complications of Diabetes Mellitus and a common cause of hospitalization. In patients admitted to the hospital for DKA, routine practice is to screen for source of infection as a trigger of the hyperglycaemic state. Although workup and medical management of patients presenting with DKA/HHS has been standardized, the COVID-19 pandemic has brought on new challenges to consider. This case will highlight these considerations and dissect the dichotomy in treatment of patients with DKA/HHS and co-existing COVID-19 pneumonia. CASE PRESENTATION: An 83 y/o female with Insulin-dependent Diabetes Mellitus presents with lethargy and fatigue. On admission, she was normotensive with elevated HR/RR, saturating 90% on RA and T-max of 99.9. Lab-work showed glucose of 726, High Anion-Gap Metabolic Acidosis, PH of 7.3 on ABGs, leukocytosis and high serum ketones. Although SIRS criteria were present on admission, it was thought to be confounded by presence of DKA. Per protocol, cardiovascular emergencies and non-compliance were ruled out prior to infectious workup. U/A was unremarkable while CXR showed B/L ground-glass opacities. Due to presentation during the SARS-CoV-2 pandemic, patient underwent viral PCR screening and tested positive. She was admitted to ICU and started on IV Insulin & IV fluid hydration for DKA. BMP was done Q4-6hrs to address metabolic disturbances while reducing exposure for medical staff. She was successfully transitioned to Sub-Q Insulin. corticosteroids were avoided to prevent worsening hyperglycemia. IV fluids were discontinued upon initiation of po intake. Patient was discharged in stable condition, without worsening respiratory status. DISCUSSION: Infection is one of the most common culprits of hyperglycemic crisis in diabetic patients. During the COVID-19 pandemic, screening for this viral infection is imperative to guide clinical decision making. As clinical studies have emerged, some guidelines now suggest Sub-Q insulin therapy in place of IV Insulin in order to reduce the need for monitoring and exposure of health-care workers. Treatments of these diseases are contradictory. In hyperglycemic state, IVF plays a crucial role in reducing mortality while in COVID-19 pneumonia, it has the potential to worsen respiratory status. On the other hand, use of corticosteroids in COVID-19 infection is fundamental to reduce the burden of systemic inflammation, while it may cause worsening glycemic status in uncontrolled diabetes mellitus. CONCLUSIONS: Routine infectious screening during a pandemic must include testing for COVID-19. Decision regarding IV fluid hydration, initiation of corticosteroids, and type of insulin therapy should be done on case-to-case basis. Further studies, scoring criteria, and consideration of other co-morbidities may help guide clinical management of these two pathologies side by side. REFERENCE #1: Francisco J. Pasquel, MD. "Diabetic Ketoacidosis Among Patients Hospitalized With or Without COVID-19." JAMA Network Open, JAMA Network, 10 Mar. 2021, jamanetwork.com/journals/jamanetworkopen/fullarticle/2777312. REFERENCE #2: Rao, Sanjana et al. "Diabetic ketoacidosis in patients with COVID-19." The American Journal of the Medical Sciences, 25 Nov. 2020, doi:10.1016/j.amjms.2020.11.027 REFERENCE #3: "Inpatient Insulin Protocols - COVID-19." Inpatient Insulin Protocols - COVID-19 | American Diabetes Association, professional.diabetes.org/content-page/inpatient-insulin-protocols-covid-19. DISCLOSURES: No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Victoria Gonzalez, source=Web Response No relevant relationships by Sourabh Sourabh, source=Web Response No relevant relationships by DANYAL TAHERI ABKOUH, source=Web Response

6 Evaluation of the Shock Index for Out-of-Hospital Sepsis Recognition

The purpose of this study was to assess the utility of sepsis suspicion and field vital signs, including calculation of SI and MSI in the out-of-hospital setting as a predictor for sepsis and sepsis-related outcomes including hyperlactatemia ≥2 mmol, as a marker of sepsis severity and a surrogate indicator for poor prognosis, and as a predictor for ICU admission and 28-day mortality. The authors present their real-world experience in a county EMS system evaluating the correlation of out-of-hospital shock index with hospital lactate, considered a marker for sepsis. This was a prospective observational study conducted as part of our county EMS system’s quality and research program. Our IRB-approved out-of-hospital research registry uses a comprehensive database and record-keeping system that prospectively identifies and collects relevant data for all potential sepsis cases. Patients with abnormal vital signs meeting SIRS criteria and either having suspected infection, or a shock index (defined as heart rate [HR]/systolic blood pressure [SBP] >1.0) or modified shock index [MSI] (defined as HR/mean arterial pressure <0.7 or > 1.3), or having high risk factors such as being from a nursing home or having human immunodeficiency virus, are called in as sepsis alerts (figure 1). Data were analyzed using JMP Pro 14.0. Contingency analyses with Fisher’s exact test and Pearson correlation were performed on serum lactate vs. sepsis diagnosis and in-hospital death, with relative risks calculated. A total of 1426 patients over the 24-month period were transported to five main receiving hospitals. The median age was 71 years, with an interquartile range of 60-80 years. The cohort was 45% female, 85% Caucasian, 14% Black, and 1% Hispanic. The initial shock index (SI1) ranged from 0.260 to 2.840 with a median of 1.11, and an IQR of 0.94 to 1.34. Sixty-eight percent had a “positive” SI1 (>1.0). The initial modified shock index ranged from 0.336 to 3.727, with a median of 1.465 and an IQR of 1.26 to 1.72. Seventy-four percent of the cohort had a “positive” MSI (<0.7, or >1.3). Three percent had MSI <0.7, while 71% had MSI > 1.3. 1321 patients (92%) had repeat vitals during transport, so a second SI was also calculated. The second SI (SI2) was elevated in 41%. All patients with elevated serum lactate were admitted to the hospital for sepsis. An elevated serum lactate was significantly associated with being diagnosed with sepsis (Pearson correlation, P<0.0001) with a relative risk of 38 (95% CI 20-72). Patients who were had an elevated SI were significantly more likely to be admitted for sepsis (P<0.0001, 95% CI 0.1038 to 0.2714). An elevated shock index mirrors an elevated lactate and as such appears to provide a reliable “invisible lactate” surrogate for use in the field.

PD26-09 USING THE QUICK SEQUENTIAL ORGAN FAILURE ASSESSMENT SCORE TO PREDICT SEPTIC SHOCK AFTER URETERAL STENTING FOR PATIENTS WITH URETERAL STONE AND PRESUMED URINARY TRACT INFECTION

You have accessJournal of UrologyStone Disease: Surgical Therapy III (PD26)1 Sep 2021PD26-09 USING THE QUICK SEQUENTIAL ORGAN FAILURE ASSESSMENT SCORE TO PREDICT SEPTIC SHOCK AFTER URETERAL STENTING FOR PATIENTS WITH URETERAL STONE AND PRESUMED URINARY TRACT INFECTION Jason Lee, Christina Kottooran, Alan Yaghoubian, Nikil Uppaluri, Kate Hanson, Michael Borofsky, and Brian Eisner Jason LeeJason Lee More articles by this author , Christina KottooranChristina Kottooran More articles by this author , Alan YaghoubianAlan Yaghoubian More articles by this author , Nikil UppaluriNikil Uppaluri More articles by this author , Kate HansonKate Hanson More articles by this author , Michael BorofskyMichael Borofsky More articles by this author , and Brian EisnerBrian Eisner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002019.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recent studies have reported that qSOFA criteria may be superior to traditionally used SIRS criteria for prediction of urosepsis. The purpose of the current study was to compare qSOFA and SIRS criteria ability to predict septic shock in patients who present to the emergency department with an obstructing ureteral stone and concern for urinary tract infection. METHODS: An IRB-approved retrospective review was performed at two institutions. All patients who met each of the following criteria during the time period from July 2016 to April 2020 were included in the study: emergency department visit with obstructing ureteral stone, concern for urinary tract infection documented in consultation note, and ureteral stent placement. The primary outcome of interest was the development of post-operative septic shock defined by hypotension requiring vasopressor support for at least one hour. Patients who required vasopressor treatment prior to ureteral stenting were excluded from the analysis. All data were collected between the time of emergency room presentation to the time of stent placement. RESULTS: The study included 187 patients with a mean age of 58.8±18 and gender distribution of 60% female: 40% male. 35 of 143 patients (18.7%) met the criteria for postoperative septic shock. SIRS criteria were met for 103 patients (55.1%) for the entire cohort and 30 patients who experienced septic shock. qSOFA criteria were met for 24 patients (12.8%) in the entire cohort and 18 patients who experienced septic shock. Specificity for postoperative sepsis was significantly higher for qSOFA than for SIRS criteria (75 vs 29.1%, McNemar test p<0.001). Sensitivity was higher for SIRS criteria than for qSOFA (85.7 vs 51.4%, McNemar test p<0.01). qSOFA criteria had a significantly higher positive predictive value than SIRS (89.6% vs. 29.1%) while negative predictive values were similar (89.6 vs. 94%). CONCLUSIONS: qSOFA score demonstrated superior specificity and positive predictive value for post-operative septic shock than SIRS criteria in this study, whereas SIRS criteria demonstrated superior sensitivity. qSOFA score may be a useful tool for emergency evaluation of patients who present with ureteral stone and urinary tract infection. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e440-e441 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jason Lee More articles by this author Christina Kottooran More articles by this author Alan Yaghoubian More articles by this author Nikil Uppaluri More articles by this author Kate Hanson More articles by this author Michael Borofsky More articles by this author Brian Eisner More articles by this author Expand All Advertisement Loading ...

Comparison of QSOFA Score and SIRS Criteria for the Prediction of Sepsis Outcome in Patients with a Suspected Bacterial Infection outside the Intensive Care Unit in the North of Iran

Comparison of QSOFA Score and SIRS Criteria for the Prediction of Sepsis Outcome in Patients with a Suspected Bacterial Infection outside the Intensive Care Unit in the North of Iran

National Early Warning Score (NEWS) and Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Validation in AML Patient during Febrile Neutropenia

Acute mieloid leukemia (AML) patients are at high risk of infections during the neutropenia period post chemotherapy. Fever often is the first sign of a deterioration of the patient. Better outcomes are reached with early diagnosis and prompt interventions, but nowadays there are not satisfactory diagnostic tools. Recently the quick Sequential (Sepsis Related) Organ Failure Assessment (qSOFA) was proven predicting out-Intensive Care Unit (ICU) mortality in a large cohort of miscellaneous patients. Also the National Early Warning Score (NEWS) was proposed predicting in hospital mortality. qSOFA score consists of three parameters, each of wich are allocated with one point: respiration rate > or = 22/min, systolic blood pressure < or = 100 mmHg and altered mental status. NEWS instead is a warning score that evaluates seven clinical parameters, each of wich are allocated with 0-3 points.The aim of our study was to assess the validation of the NEWS and the qSOFA in a homogeneous cohort of AML patients during the neutropenic fever period.All patients underwent chemotherapy in induction course and cases with complete remission continued the therapy with consolidation cycles. For each patient data about age, infections, antimicrobical therapy, coltures were collected. Furthermore for each fever day during aplasia period aggregate score of NEWS e qSOFA were calculated. In addition data on clinical deterioration like SIRS criteria, amine necessity, respiratory failure, ventilation support, ICU admission and death were analyzed. The ability of the NEWS and the qSOFA score on prediction of the clinical deterioration was analyzed by calculating the area under the curve (AUROC) using the logistic regression model.A total of 334 consecutive patients were evaluated; the median age was 53 years old. After induction course a complete remission was achieved in 238 patients (71%), 74 were resistant (22%) and 22 died (7%). 112 patients (34%) underwent allogeneic stem cell transplantation. A total of 2792 neutropenic fever days were analyzed. There was a significant difference between the NEWS evaluated in the first day of fever in Gram negative bacteriemia (median NEWS = 2) respect on Gram positive one (median NEWS =1) (p=0.0006). also qSOFA was higher in the Gram negative bacteriemia (p=0.004). Both NEWS and qSOFA were able to predict faithfully different outcomes of clinical deterioration in the same day of the evaluation of the scores: for example the NEWS AUROC for the use of amine was 0.899 and the qSOFA AUROC was 0.868; the NEWS AUROC for the ICU admission was 0.917 and the qSOFA AUROC was 0.916; lastly NEWS AUROC for the death was 0.984 and qSOFA AUROC 0.969. The two scores were able to predict these outcomes also 24 hours after the scores determination in lag-1 analysis: the NEWS AUROC for the use of amine was 0.885 and the qSOFA AUROC was 0.837; the NEWS AUROC for the ICU admission was 0.933 and the qSOFA AUROC was 0.910; lastly NEWS AUROC for the death was 0.924 and qSOFA AUROC 0.884. Besides in the lag-2 analysis (48 hours after the score determination) NEWS and qSOFA score were accurate to predict outcomes: the NEWS AUROC for the use of amine was 0.837 and the qSOFA AUROC was 0.772; the NEWS AUROC for the ICU admission was 0.888 and the qSOFA AUROC was 0.830; lastly NEWS AUROC for the death was 0.894 and qSOFA AUROC 0.827.Actually this analysis is the first validation of the NEWS and the qSOFA in a large AML patients cohort during neutropenic fever. So NEWS as qSOFA may be considered valid tools to evaluate critical hematologic patients in intensive chemoterapy induced aplasia. DisclosuresVitolo:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Mundipharma: Honoraria; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Gilead: Honoraria; Takeda: Honoraria.

The Significance of Routine Biochemical Markers in Patients with Sepsis

Background: Sepsis is a highly complex and fatal syndrome, considered to be the main cause of death in the intensive care unit. Early diagnosis is beneficial to reduce the mortality and improve the prognosis of patients. Therefore, we look forward to finding cheap and fast diagnostic criteria to quickly assess the patient’s condition. Methods: Our study enrolled 499 patients in our hospital from January to 2020, and 96 healthy cases in the same period. Used the diagnostic criteria of bacterial infection, SIRS criteria and Sepsis-2 consensus criteria, 499 patients were divided into 4 groups: sepsis group (n=300), SIRS group (n=151), infection group (n=48). We collected the results of routine laboratory tests, inflammation indicators and blood culture results of these patients. Results: The sepsis group compared with the control group, many indicators had significant statistical differences. D-dimer, CRP and PCT had higher diagnostic efficiency. Compared between the infection group and the SIRS group, PLT and IL-6 were statistically different, and have a certain diagnostic value. Sepsis group VS infection group, WBC, IL-6, NE and TBIL showed significant differences. Among them, NE had the highest diagnostic efficiency and the highest specificity (95.8%). Conclusions: This retrospective study shows that NE, WBC and D-dimer are helpful for early diagnosis of sepsis in which of them D-dimer performs best. WBC and NE can be used to distinguish sepsis from common infection. This result can provide a timely and convenient assessment tool for early diagnosis of sepsis.

Pre-transplant T-cell Clonality: An Observational Study of a Biomarker for Prediction of Sepsis in Liver Transplant Recipients.

This study investigated the ability of pre-transplant T-cell clonality to predict sepsis after liver transplant (LT). Sepsis is a leading cause of death in LT recipients. Currently, no biomarkers predict sepsis before clinical symptom manifestation. Between December 2013 and March 2018, our institution performed 478 LTs. After exclusions (eg, patients with marginal donor livers, autoimmune disorders, nonabdominal multi-organ, and liver retransplantations), 180 consecutive LT were enrolled. T-cell characterization was assessed within 48 hours before LT (immunoSEQ Assay, Adaptive Biotechnologies, Seattle, WA). Sepsis-2 and Sepsis-3 cases, defined by presence of acute infection plus ≥2 SIRS criteria, or clinical documentation of sepsis, were identified by chart review. Receiver-operating characteristic analyses determined optimal T-cell repertoire clonality for predicting post-LT sepsis. Kaplan-Meier and Cox proportional hazard modeling assessed outcome-associated prognostic variables. Patients with baseline T-cell repertoire clonality ≥0.072 were 3.82 (1.25, 11.40; P = 0.02), and 2.40 (1.00, 5.75; P = 0.049) times more likely to develop sepsis 3 and 12 months post-LT, respectively, when compared to recipients with lower (<0.072) clonality. T-cell repertoire clonality was the only predictor of sepsis 3 months post-LT in multivariate analysis (C-Statistic, 0.75). Adequate treatment resulted in equivalent survival rates between both groups: (93.4% vs 96.2%, respectively, P = 0.41) at 12 months post-LT. T-cell repertoire clonality is a novel biomarker predictor of sepsis before development of clinical symptoms. Early sepsis monitoring and management may reduce post-LT mortality. These findings have implications for developing sepsis-prevention protocols in transplantation and potentially other populations.

Leukocytes Ratios in Feline Systemic Inflammatory Response Syndrome and Sepsis: A Retrospective Analysis of 209 Cases.

Simple SummaryFeline sepsis is a life-threatening syndrome in which blood diagnostic and prognostic markers are limited. We investigated the differences in neutrophil-to-lymphocyte ratio and other white-blood-cell ratios between healthy and sick cats (systemic inflammation (SIRS) and/or septic cats) and then the use of these ratios as prognostic markers. This study included 76 healthy cats (blood-donors), 54 cats with SIRS and 79 cats with sepsis. A cat with an NLR > 4.53 had a 44-fold chance to have SIRS or sepsis, although only BLR and BNLR were different between SIRS and sepsis groups. The NLR has been shown as a prognostic marker in sick cats. This is a novel investigation about leukocyte ratios in the cat, and the NLR may be used as a prognostic parameter in cats with SIRS or sepsis, and BLR and BNLR demonstrate themselves as promising tools in differentiating SIRS from sepsis.Sepsis is a challenging condition in which hematological prognostic and diagnostic markers in cats are limited. The aims of this study were to test if there are any differences in leukocyte ratios (NLR, BLR and BNLR) between healthy, SIRS and septic cats (sick cats), and if, within sick cats, NLR, BLR and BNLR may be prognostic markers. A retrospective medical database study included 76 healthy cats (blood-donors), 54 SIRS and 79 septic cats. SIRS group was defined if cats fulfilled SIRS criteria. Sepsis was confirmed with an infectious focus on cytology or a positive culture for bacterial infection. Leukocyte ratios were compared among the three study groups and between survivors and non-survivors in sick cats. NLR resulted significantly higher in the sick group compared to healthy cats (p < 0.0001), although NLR was not different between SIRS and sepsis. An NLR > 4.53 had a sensitivity of 76% and a specificity of 93.4% to detect SIRS/sepsis (OR 44.8 95%CI 17–107). Only BLR and BNLR were significantly different between SIRS and sepsis. NLR was associated with mortality in the sick group (p = 0.04). Although NLR resulted higher in sick cats than healthy, BLR and BNLR demonstrated as promising tools in differentiating SIRS from sepsis. NLR was associated with mortality in sick cats.

Inflammatory Bowel Disease (IBD) and immunosuppression do not worsen the prognosis of COVID-19. Results from the ENEIDA Project of GETECCU

BackgroundThe exhaustive registry of COVID-19 cases in patients with IBD is a unique opportunity to learn how to deal with this infection, especially in reference to the management of immunosuppressive treatment, isolation measures or if the disease is more severe in IBD patients due to immunosuppression. With these premises, the aims of this study were to know the incidence and characteristics of COVID-19 in the ENEIDA cohort during the first wave of the pandemic; the outcomes among those under immunosuppressants/biologics for IBD; the risk factors for contracting the infection and poor outcomes; and the impact of the infection after three-month follow-up.MethodsProspective observational cohort study of all IBD patients with COVID-19 included in the ENEIDA registry (with 60.512 patients in that period) between March and July 2020, with at least 3 months of follow-up. Any patient with a confirmed (by PCR or SARS-CoV-2 serology) or probable (suggestive clinical picture) infection was considered as a case.ResultsA total of 484 patients with COVID-19 from 63 centres were included: 247 Crohn’s disease, 223 ulcerative colitis and 14 unclassified colitis; median age 52 years (IQR: 42–61), 48% women and 44% ≥1 comorbidity. Diagnosis was made by PCR: 63% and serology: 35%. The most frequent symptoms: fever (69%), followed by cough (63%) and asthenia (38%). During lockdown 78% followed strict isolation. 35% required hospital admission (ICU: 2.7%) and 12% fulfilled criteria for SIRS upon admission. 16 patients died from COVID-19 (mortality:3.3%). 12% stop IBD medication during COVID-19. At 3 months, taken into account all included cases, 76% were in remission of IBD. Male gender (OR 1.56; 95%CI:1–2.4, p=0.05), ≥40 years of age (OR 2.55; 95% CI:1.4–4.8; p=0.004), Charlson score ≥1 (OR 2.1; 95% CI:1.3–3.5; p=0.004), and systemic steroids <3 months before infection (OR 1.8; 95%CI:1–1.6; p= 0.032), were risk factors for hospitalisation due to COVID-19, while occupation considered of risk was actually protective (OR 0.58; 95%CI:0.3–0.99; p=0.046). A Charlson score ≥ 1 (OR 5.5; 95%CI:1.5–20.3; p=0.001) and the use of aminosalicylates at COVID-19 diagnosis (OR 4.6;95%CI:1.2–17; p=0.023) were associated with ICU admission. Age ≥60 years (OR 6.5; 95%CI:1.7–25.5; p=0.007) was the only risk factor for COVID-19 related death.ConclusionIBD does not seem to worsen the prognosis of COVID-19, even when immunosuppressants and biological drugs are used. Age and comorbidity are the most important prognostic factors for more severe COVID-19 in IBD patients. The use of aminosalicylates and the risk of a worse outcome deserves a deeper analysis.Funded by the Carlos III Health Institute (COV20 / 00227).

The Relationship Between SOFA, qSOFA, SIRS Criteria Scoring Systems and 1-Year Mortality in Patients Followed Up in Level 3 Intensive Care Unit after Orthopedic Surgery

Predictive scoring systems are designed to predict patients' discharge status, patient mortality, Intensive Care Unit(ICU) mortality and lenght of hospital stay. These scoring systems, which are aimed to standardize and form a common language in terms of evaluating patient general health situation, are used in the evaluation of patients in many ICU.In this study, we aimed to evaluate the ability of the scoring systems that can be used to predict the mortality of the patients who will be followed up in the ICU after orthopedic surgery and predict the mortality that occurs in the first year outside the hospital. We established our hypothesis that there will be no difference between the predictive power of predictive scoring systems, which can be used as a marker of mortality, since relatively short-term hospitalizations occur in the ICU after orthopedic surgery. Our study was designed as a single center retrospective. Between January 2017 and August 2018, all patients undergoing level 3 intensive care follow-up were identified in the automation system. After the evaluation of 146 patients' files and automation system data, patients who were in compliance with the inclusion and exclusion criteria were identified. A total of 40 patients were included in the study. The mean age was 75.69 (SD = 8.66 years), 50% male and 50% female. Fifteen patients (37.5%) died during their first year follow-up. When the patients were evaluated as survivors and non-survivors in the first year, it was observed that there was a significant difference between the groups in terms of quantitative variables in terms of early postoperative GCS and in terms of early postoperative oxygen saturationThere was no significant difference between the two groups in terms of qualitative variables. (P&amp;gt; 0.005) An appropriate mortality predictor score should be selected to standardize follow-up in intensive care unit. As a result of our study, there was no significant relationship between gropus SOFA, qSOFA scores and SIRS critera met suggested that these scoring systems were not suitable for predicting 1-year mortality in our patient group. We believe that specific criteria should be established with studies with larger series and more criteria.

Two-stage prediction model for in-hospital mortality of patients with influenza infection

BackgroundInfleunza is a challenging issue in public health. The mortality and morbidity associated with epidemic and pandemic influenza puts a heavy burden on health care system. Most patients with influenza can be treated on an outpatient basis but some required critical care. It is crucial for frontline physicians to stratify influenza patients by level of risk. Therefore, this study aimed to create a prediction model for critical care and in-hospital mortality.MethodsThis retrospective cohort study extracted data from the Chang Gung Research Database. This study included the patients who were diagnosed with influenza between 2010 and 2016. The primary outcome of this study was critical illness. The secondary analysis was to predict in-hospital mortality. A two-stage-modeling method was developed to predict hospital mortality. We constructed a multiple logistic regression model to predict the outcome of critical illness in the first stage, then S1 score were calculated. In the second stage, we used the S1 score and other data to construct a backward multiple logistic regression model. The area under the receiver operating curve was used to assess the predictive value of the model.ResultsIn the present study, 1680 patients met the inclusion criteria. The overall ICU admission and in-hospital mortality was 10.36% (174 patients) and 4.29% (72 patients), respectively. In stage I analysis, hypothermia (OR = 1.92), tachypnea (OR = 4.94), lower systolic blood pressure (OR = 2.35), diabetes mellitus (OR = 1.87), leukocytosis (OR = 2.22), leukopenia (OR = 2.70), and a high percentage of segmented neutrophils (OR = 2.10) were associated with ICU admission. Bandemia had the highest odds ratio in the Stage I model (OR = 5.43). In stage II analysis, C-reactive protein (OR = 1.01), blood urea nitrogen (OR = 1.02) and stage I model’s S1 score were assocaited with in-hospital mortality. The area under the curve for the stage I and II model was 0.889 and 0.766, respectively.ConclusionsThe two-stage model is a efficient risk-stratification tool for predicting critical illness and mortailty. The model may be an optional tool other than qSOFA and SIRS criteria.

Clinical and microbiological characterization of sepsis and evaluation of sepsis scores.

BackgroundDespite the necessity of early recognition for an optimal outcome, sepsis often remains unrecognized. Available tools for early recognition are rarely evaluated in low- and middle-income countries. In this study, we analyzed the spectrum, treatment and outcome of sepsis at an Ethiopian tertiary hospital and evaluated recommended sepsis scores.MethodsPatients with an infection and ≥2 SIRS criteria were screened for sepsis by SOFA scoring. From septic patients, socioeconomic and clinical data as well as blood cultures were collected and they were followed until discharge or death; 28-day mortality was determined.ResultsIn 170 patients with sepsis, the overall mortality rate was 29.4%. The recognition rate by treating physicians after initial clinical assessment was low (12.4%). Increased risk of mortality was significantly associated with level of SOFA and qSOFA score, Gram-negative bacteremia (in comparison to Gram-positive bacteremia; 42.9 versus 16.7%), and antimicrobial regimen including ceftriaxone (35.7% versus 19.2%) or metronidazole (43.8% versus 25.0%), but not with an increased respiratory rate (≥22/min) or decreased systolic blood pressure (≤100mmHg). In Gram-negative isolates, extended antimicrobial resistance with expression of extended-spectrum beta-lactamase and carbapenemase genes was common. Among adult patients, sensitivity and specificity of qSOFA score for detection of sepsis were 54.3% and 66.7%, respectively.ConclusionSepsis is commonly unrecognized and associated with high mortality, showing the need for reliable and easy-applicable tools to support early recognition. The established sepsis scores were either of limited applicability (SOFA) or, as in the case of qSOFA, were significantly impaired in their sensitivity and specificity, demonstrating the need for further evaluation and adaptation to local settings. Regional factors like malaria endemicity and HIV prevalence might influence the performance of different scores. Ineffective empirical treatment due to antimicrobial resistance is common and associated with mortality. Local antimicrobial resistance statistics are needed for guidance of calculated antimicrobial therapy to support reduction of sepsis mortality.

Sepsis induced sequential organ failure assessment score as a prognostic marker in surgical sepsis: a study of 30 cases in 02 years

Background: For the last few decades critical care medicine has been reinventing and fine-tuning organ dysfunction grading to establish a survival scoring system to accurately predict survivality and organ salvageability of critically ill patient in intensive care unit (ICU). The sequential organ failure assessment (SOFA) score assesses the performance of several organ systems in the body and assigns a score, where higher the SOFA score, higher the likelihood of mortality and morbidity. Early prediction of outcome in surgical sepsis is very likely to aid suitable modification of management strategies 13. This may improve prognosis in such patients and prevent mortality to some extent. Methods: Observational and prospective study of 30 cases, aged&gt;18 years &amp; patients admitted to post-operative ward and surgical intensive care unit (SICU) with suspected surgical infection, and with two or more criteria of SIRS. Results: In this study out of total 30 patients 63.3% patients survived and 36.6% succumbed to their illness. Our study depicted significant increase in mortality rate when the SOFA score was above 12. Ventilated patient showed a higher mortality rate. Delta, mean, total SOFA Score were statistically significant in our study.Conclusions: SOFA score is useful in predicting mortality and morbidity in critically ill patients, because has a strong correlation between a rise in the score and mortality in all stages of admission. In our study, out of 09 patients whose T0 SOFA score was very high (above 12) out of which 03 patients only survived.

Comparison of REMS, NEWS, qSOFA scales and SIRS criteria in sepsis prediction for patients with confirmed SARS-CoV-2 infection: retrospective observational study

Introduction. Novel coronavirus disease is often accompanied by sepsis. This leads us to search of sepsis prediction tools. Objectives. Comparison of REMS, NEWS, qSOFA scales and SIRS criteria in sepsis prediction for patients with confirmed SARS-CoV-2 infection. Materials and methods. 167 medical cards retrospective analysis of patients with confirmed SARS-CoV-2 infection on admission to ICU. Results. In sepsis prediction only NEWS (0,819 [95% CI 0.738–0,884]) showed resolution high enough to serve as supplemental clinical information. REMS (0.798 [95% CI 0.715–0.866]), qSOFA (0.716 [95% CI 0.626–0.795]) and SIRS criteria (0.710 [95% CI 0.620–0.790]) showed insufficient resolution in sepsis prediction for patients with SARS-CoV-2. NEWS in pairwise comparison showed significantly better resolution than qSOFA (p = 0.002) and SIRS criteria (p = 0.013). All scales showed good calibration. Conclusions. Only NEWS scale showed good resolution and calibration and can be used as supplemental clinical information in sepsis prediction for patients with SARS-CoV-2 infection.

Quick Sequential Organ Failure Assessment Versus Systemic Inflammatory Response System in Early Detection of Sepsis in Emergency Department

Background: Sepsis is a life threating medical condition where infection leads to massive inflammatory response and eventually lead to organ dysfunction. It continues to pose a significant health threat despite remarkable developments in critical care medicine and extensive study of septic patients. Early recognition and treatment of sepsis in emergency department (ED) is important to reduce mortality, hospital length of stay and morbidity. Objective: This study was aimed to validate the performance of qSOFA scoring system and SIRS criteria in early sepsis diagnosis in the Emergency Department. Patient and method: This prospective observational clinical study was carried out in Emergency Department (ED) on 100 patients with suspected infection presented and admitted at o Mansoura University Emergency Hospital from February 2019 to February 2020. Patients were divided into two groups: infection group with qSOFA –ve criteria and sepsis group with qSOFA +ve group. We compare between qSOFA and SIRS scores in both groups. Results: The study demonstrated that organ dysfunction >2, 2ry to infection (according to sepsis definition by sepsis-3 task force) was more frequently reported among qSOFA + SIRS + group, compared to qSOFA - SIR – group. Moreover, both qSOFA and SIRS had comparable sensitivity (100%) in prediction of mortality within 1 week, while qSOFA demonstrated higher specificity (53.3%) in comparison with SIRS (20%). Both scores had comparable sensitivity for prediction ICU admission and of mechanical ventilation (86.67 and 88.9) whereas qSOFA demonstrated higher specificity than SIRS for ICU admission (94.29 versus 71.43) as well as mechanical ventilation (82.9 versus 63.41). Conclusion: It could be concluded that qSOFA is considered as specific not sensitive tool, while SIRS is more sensitive but not specific score for sepsis detection in emergency room.

An observational cohort study of the performance of the REDS score compared to the SIRS criteria, NEWS2, CURB65, SOFA, MEDS and PIRO scores to risk-stratify emergency department suspected sepsis

Objective To compare the performance of the Risk-stratification of Emergency Department suspected Sepsis (REDS) score to the SIRS criteria, NEWS2, CURB65, SOFA, MEDS and PIRO scores, to risk-stratify Emergency Department (ED) suspected sepsis patients for mortality. Method A retrospective observational cohort study of prospectively collected data. Adult patients admitted from the ED after receiving intravenous antibiotics for suspected sepsis in the year 2020, were studied. Patients with COVID-19 were excluded. The scores stated above were calculated for each patient. Receiver operator characteristics (ROC) curves were constructed for each score for the primary outcome measure, all-cause in-hospital mortality. The area under the ROC (AUROC) curves and cut-off points were identified by the statistical software. Scores above the cut-off point were deemed high-risk. The test characteristics of the high-risk groups were calculated. Comparisons were based on the AUROC curve and sensitivity for mortality of the high-risk groups. Previously published cut-off points were also studied. Calibration was also studied. Results Of the 2594 patients studied, 332 (12.8%) died. The AUROC curve for the REDS score 0.73 (95% confidence interval [CI] 0.72–0.75) was significantly greater than the AUROC curve for the SIRS criteria 0.51 (95% CI 0.49–0.53), p < .0001 and the NEWS2 score 0.69 (95% CI 0.67–0.70), p = .005, and similar to all other scores studied. Sensitivity for mortality at the respective cut-off points identified (REDS ≥3, NEWS2 ≥ 8, CURB65 ≥ 3, SOFA ≥3, MEDS ≥10 and PIRO ≥10) was greatest for the REDS score at 80.1% (95% CI 75.4–84.3) and significantly greater than the other scores. The sensitivity for mortality for an increase of two points from baseline in the SOFA score was 63% (95% CI 57.5–68.2). Conclusions In this single centre study, the REDS score had either a greater AUROC curve or sensitivity for mortality compared to the comparator scores, at the respective cut-off points identified. KEY MESSAGES The REDS score is a simple and objective scoring system to risk-stratify for mortality in emergency department (MED) patients with suspected sepsis. The REDS score is better or equivalent to existing scoring systems in its discrimination for mortality.

91. Implementing Criteria to Reduce Blood Cultures Ordering: A Pre- and Post-Intervention Retrospective Study in a Critical Access Hospital

BackgroundBlood culture utilization has been performed widely. Typically, clinicians order blood cultures in patients whom bacteremia is suspected. Our previous study showed that 35% of blood cultures performed in May 2019 could have been prevented since they did not meet the certain criteria. This study sought to examine the outcomes after education intervention by implementing criteria of blood culture ordering whether it could reduce unnecessary blood cultures.MethodsElectronic medical records of adult patients who had blood cultures done during pre-and post-study period were reviewed. Demographic data, clinical presentation, vital signs, location, quantities and sites of blood cultures were obtained. The measurement of qSOFA, SIRS and severe sepsis criteria were collected on the presentation. There were some clinical prediction rules for blood stream infection described in the previous studies. For this study, we use the criteria of at least 2 SIRS and/or at least one of the qSOFA criteria or severe sepsis to be a minimum indication for ordering blood cultures. The follow-up study was done after 6 weeks of educational intervention with implementation of criteria. Chi-square was used to compare the differences between two groups.ResultsThere were a total of 165 patients included in our study (112 in pre- and 53 in post-intervention group). There were a total of 18 patients with positive blood cultures (12/112;10.71% in pre-intervention gr. vs 6/53;11.32% in post-intervention gr., p=0.91). Six out of 18 (33%) were deemed to be contaminated (3/12;25% vs 3/6;50%, p=0.29). Gram positive cocci were the most common organisms of the true positive blood cultures (10/12;83%). Of 165 patients, 78 (47%) had at least one of qSOFA (47/112;41% vs 31/53;58%, p=0.05), 18 (11%) had met severe sepsis criteria (9/112;8% vs 9/53;17%, p=0.09). There were 47 (28%) patients who had less than 2 criteria of SIRS and did not meet either criteria of qSOFA or severe sepsis (39/112; 35% vs 8/53; 15%, chi 6.87, p< 0.01). There was no true bacteremia in this group of patients.ConclusionOur study found that implementation of criteria for blood cultures successfully reduces the unnecessary blood cultures orders approximately 20% without missing true bacteremia in suspected patients.Disclosures All Authors: No reported disclosures