Systemic Inflammatory Response Syndrome Criteria Research Articles

A Comparative Study on Predictive Validity of Modified Shock Index, Shock Index, and Age Shock Index in Predicting the Need for Mechanical Ventilation among Sepsis Patients in a Tertiary Care Hospital.

The shock index (SI), modified shock index (MSI), and age multiplied by SI (ASI) are used to assess the severity of shock. They are also used to predict the mortality of trauma patients, but their validity for sepsis patients is controversial. The aim of this study is to assess the predictive value of the SI, MSI, and ASI in predicting the need for mechanical ventilation after 24 h of admission among sepsis patients. A prospective observational study was conducted in a tertiary care teaching hospital. Patients with sepsis (235) diagnosed based on systemic inflammatory response syndrome criteria and quick sequential organ failure assessment were included in the study. The need for mechanical ventilation after 24 h is the outcome variables MSI, SI, and ASI were considered as predictor variables. The utility of MSI, SI, and ASI in predicting mechanical ventilation was assessed by receiver operative curve analysis. Data were analyzed using coGuide. Among the study population, the mean age was 56.12 ± 17.28 years. MSI value at the time of disposition from the emergency room had good predictive validity in predicting mechanical ventilation after 24 h, as indicated by the area under the curve (AUC) of 0.81 (P < 0.001), SI and ASI had fair predictive validity for mechanical ventilation as indicated by AUC (0.78, P < 0.001) and (0.802, P < 0.001), respectively. SI had better sensitivity (78.57%) and specificity (77.07%) compared to ASI and MSI in predicting the need for mechanical ventilation after 24 h in sepsis patients admitted to intensive care units.

An investigation of temperature and fever burdens in patients with sepsis admitted from the emergency department to the hospital.

We sought to collect granular data on temperature burden to further explore existing conflicting information on the relationship between temperature alterations and outcomes in patients with sepsis requiring hospital admission. This was a prospective cohort study that enrolled a convenience sample of patients with sepsis or septic shock admitted to the hospital from the emergency department (ED). A "unit of temperature burden (UTB)" was defined as >1°C (1.8°F) above or below 37°C (98.6°F) for 1 min. Fever burden was defined as the number of UTBs >38°C (100.4°F). The primary objective was to calculate the fever burden in patients with sepsis during their ED stay. This was analyzed for patients who present to triage febrile or hypothermic and also for those who developed temperature abnormalities during their ED stay. The secondary objectives were correlating fever and hypothermia burden with in-hospital mortality, Systemic Inflammatory Response Syndrome (SIRS) criteria, and the quick Sequential (Sepsis-Associated) Organ Failure Assessment (qSOFA) score and identification of patients who may benefit from early implementation of targeted temperature management. A total of 256 patients met the inclusion criteria. The mean age of patients was 60.1 ± 18.4 years; 46% were female and 29.6% were black. The median (interquartile range [IQR]) fever burden for the fever in triage cohort (n = 99) was 364.6 (174.3-716.8) UTB and for the no fever in triage cohort (n = 157) was 179.3 (80.9-374.0) UTB (p = 0.005). The two groups had similar in-hospital mortality (6.1 vs 8.3%; p = 0.5). The median fever burden for the fever anytime cohort was 303.8 (IQR 138.8-607.9) UTB and they had lower mortality than the no fever anytime cohort (4.7% vs 11.2%; p = 0.052). Patients with fever at triage had higher mean SIRS criteria than those without (2.8 vs 2.0; p < 0.001) while qSOFA points were similar (p = 0.199). A total of 27 patients had hypothermia during their ED stay and these patients were older with higher mean SIRS criteria. Patients with sepsis and septic shock have a significant temperature burden in the ED. When comparing patients who had fever at any time during their ED stay with those who never had a fever, a trend toward an inverse relationship between fever burden and mortality was found.

Utility and impact of early diagnostic assessment of sepsis on mortality in an emergency department of a tertiary hospital in Lagos, Nigeria.

Currently, little is known about the timely application of clinical screening tools and blood sampling for decision-making in the management of patients with suspected sepsis in the accident and emergency units of hospitals in Nigeria. The aim of the study was to ascertain the association between the time taken for the conduct of serum lactate and blood culture investigations following a clinical suspicion of sepsis, and the mortality of patients admitted to a Nigerian tertiary hospital. Over a 6-month period (November 2021 to April 2022), 119 patients hospitalised for sepsis or septic shock at the Lagos University Teaching Hospital were followed until discharge or death. The proportion of patients whose serum lactate, serum procalcitonin and blood culture samples was taken was also determined. Predictors of mortality were determined using bivariate analysis and logistic regression. Kaplan-Meier plots were used to predict survival using sepsis diagnostic criteria. Eighty (67%) of 119 sepsis patients met systemic inflammatory response syndrome or quick sequential (sepsis-related) organ failure assessment criteria. Only 3 (2.5%) patients had blood cultures and serum procalcitonin and 0 (0%) had serum lactate tests. Forty-one (34.5%) patients died, but clinical and laboratory procedures for sepsis management were not linked to death. A shorter hospital stay increased the death risk (χ2 = 14.83, P = 0.002). This study revealed low compliance with sepsis care guidelines and no impact of timely clinical and laboratory procedures on sepsis mortalities. Further study is needed to explore patient care models that can improve the objective assessment and treatment of sepsis patients in emergency departments of busy tertiary hospitals.

1823. Clinical Profile and Antimicrobial Susceptibility of Invasive Extraintestinal Pathogenic Escherichia coli Disease in Hospitalized Adults Aged ≥60 Years

Abstract Background Invasive extraintestinal pathogenic Escherichia coli disease (IED) occurs more frequently with increasing age, and antimicrobial resistance (AMR) can complicate treatment. Yet IED is under-monitored by major disease surveillance systems. In addition, the diagnosis of IED can be challenging due to the diversity of clinical presentations. More research is warranted to better characterize IED. Here we report EXPECT-2 (NCT04117113) results describing the clinical profile of IED and AMR patterns of causative E. coli isolates. Methods EXPECT-2 was a prospective observational study conducted in patients aged ≥60 years with an IED and hospitalized at 8 sites in Europe, North America, and Asia. Data were collected from October 24, 2019 to January 28, 2021. IED was determined by clinical criteria of either systemic inflammatory response syndrome (SIRS) or Sequential Organ Failure Assessment (SOFA), and a positive E. coli culture either from blood (bacteremic IED), or other normally sterile body site samples and/or urine (non-bacteremic IED). Results Overall, 240 IED patients were enrolled (median age, 75 years; females: 51%); 80.4% of IED cases were bacteremic and 19.6% were non-bacteremic. IED was community-acquired in 50.4%, hospital-acquired in 20.0%, and health care–associated in 29.6% of patients. The most common source of IED was urinary tract (62.9%). Fever occurred in 51.5%, tachycardia in 58.6%, tachypnea in 24.3%, and altered mentation in 15.7% of patients. Laboratory markers of a systemic infection were observed in 86.3% of patients, including leukocytosis in 42.7% and leukopenia in 10.9% of patients. SIRS criteria (≥ 2) were met in 65.8% and SOFA criteria (≥ 2) in 60.4% of patients. According to the investigator, 76.5% of patients met criteria for sepsis and 10.6% for septic shock. At 28 days post diagnosis, 14.6% of patients were unrecovered; 12.9% had a complication of kidney dysfunction, and 4.6% had died. Of 238 patients whose E. coli isolates were tested, the AMR rates for ≥ 1 antibiotic were 62.6% in ≥ 1 drug class, 45.9% in ≥ 2 drug classes, and 35.0% in ≥ 3 drug classes. Conclusion In patients aged ≥ 60 years, IED manifested as a severe infection. AMR was frequently observed. The data suggest a need of preventive interventions for IED. Disclosures Joachim Doua, MD, MPH, Janssen: Employee|Janssen: Stocks/Bonds Jeroen Geurtsen, PhD, Janssen: Employee of Janssen Vaccines &amp; Prevention BV Oscar Go, PhD, Janssen: Employee of Janssen Research &amp; Development LLC. Michal Sarnecki, MD, Janssen: Employee|Janssen: Stocks/Bonds Bart Spiessens, PhD, Janssen: Employee Marc Bonten, MD, PhD, Astra-Zeneca: Advisor/Consultant|Janssen: Advisor/Consultant|Merck: Advisor/Consultant|Novartis: Advisor/Consultant Jan Poolman, PhD, Janssen: Janssen Vaccines &amp; Prevention B.V.|Janssen: Stocks/Bonds.

742. Identification of Barriers to Shifting Management of Diabetic Foot Infections from the Hospital Setting to a Multidisciplinary Wound Clinic

Abstract Background Hospitalized patients with diabetic foot infections (DFI) are commonly stable upon admission and lack signs of sepsis, necrotizing fasciitis, critical limb ischemia, or bacteremia. Patients are admitted for key components of DFI care: non-urgent procedures for source control; radiographic imaging; cultures; consultation with infectious diseases (ID), podiatry, or vascular surgery; and peripherally inserted central catheter (PICC) access. We aimed to identify the proportion of patients with low acuity DFI who were hospitalized and to characterize potential barriers to outpatient management. Methods Between 2020 and 2021, data from the medical record were abstracted for adult patients admitted to Michigan Medicine with an ICD-10 admission diagnosis of DFI. Patients were categorized into low and high acuity cohorts. High acuity was defined as sepsis, necrotizing fasciitis, critical limb ischemia, or bacteremia. Low acuity was defined as clinical stability (≤ 1 systemic inflammatory response syndrome (SIRS) criteria) and without high acuity criteria. The primary outcome was the prevalence of low acuity DFIs admitted to the hospital, duration of hospitalization, and associated costs. Secondary outcomes included 30-day all-cause mortality, DFI recurrence, DFI readmission, and time from clinical stability to completion of DFI care (non-urgent procedures; radiographic imaging; cultures; consultation to ID, podiatry, or vascular surgery; and PICC access). Results Of 64 hospitalized DFI patients, 37 (58%) were low acuity and 27 (42%) high acuity. All low acuity patients were clinically stable on admission with a median hospitalization length of 6.3 days. Figure 1 shows the time to completion of key components of DFI care from clinical stability. Low acuity group had DFI recurrence of 5.4%; readmission with DFI of 10.8%; and all-cause mortality of 5.4%. The median hospitalization cost for low-acuity DFI was $55,500 per patient. Conclusion More than half of hospitalized DFI patients are low acuity, and could have avoided hospitalization. These patients had a median hospitalization length of 6.3 days and total cost of $55,500. Developing a coordinated process to manage low acuity patients outpatient may avoid unnecessary hospitalizations and reduce healthcare cost. Disclosures All Authors: No reported disclosures.

1169. Derivation And Validation of an International Clinical Prognostication Model for 28-day Sepsis Mortality.

Abstract Background Survival prediction models have largely been derived and validated only in high-resource Western countries or in single center studies. We sought to create a prediction model for 28-day mortality using laboratory and physiologic parameters from 3 international sepsis cohorts and externally validated the model. Methods During 2014 to 2021, adult hospitalized patients with suspected infection were enrolled in Durham, United States (N=180) and those with suspected infection and ≥2 SIRS (Systemic Inflammatory Response Syndrome) criteria in Takeo, Cambodia (N=200), and Kumasi, Ghana (N=187). Twenty-five clinical laboratory and physiologic parameters were candidate covariates and sepsis screening scores included as comparators. First, bivariate Cox regression models were performed to determine risk of individual parameters. Then, a 10-fold cross-validated forward stepwise model selection technique was used to eliminate nonsignificant variables using a p-value &amp;lt; 0.10 and the cross-validated C-statistic was estimated. Lastly, this model was applied to an external cohort of hospitalized adults with suspected infection and ≥2 SIRS in Fort Portal, Uganda (N=331 with 9.3% 28-day mortality). Results Among 567 participants, overall mortality was 16.4% at 28-days. Mortality rate highest in Ghana (31.0%), followed by Cambodia (11.0%) and the United States (7.2%). Bivariate analyses identified hypernatremia ( &amp;gt;145 mEq/L) being associated with the highest risk of death (hazard ratio: 7.42; 95% CI: 3.65 to 15.10; Figure 1). On multivariable analysis, a 28-day mortality model including mean arterial pressure, Glasgow Coma score, blood sodium, lactate, and blood urea nitrogen (Table 1) resulted in a 10-fold cross-validated C-statistic of 0.80 (95% CI: 0.61 to 0.88). This model predicted mortality accurately in the validation cohort with a C-statistic of 0.74 (95%CI: 0.69 to 0.79). Figure 1.Forest plot for bivariate analyses for one month survival across United States, Cambodia, and Ghana cohorts. Conclusion Hypotension, altered mental status, serum sodium, serum BUN, and plasma lactate accurately identified risk of death by 28-days among those with suspected sepsis in 3 international derivation cohorts and in a validation cohort in Uganda. Our findings emphasize the importance of clinical laboratory results for sepsis risk stratification. Disclosures Ephraim L. Tsalik, MD PhD, Danaher Diagnostics, Predigen, and Biomeme: In the past 3 years, I have had held equity and consulted for Predigen and Biomeme. Currently, I am an employee of Danaher Diagnostics. Christopher W. Woods, MD MPH, Predigen, Inc: Co-founder.

Evaluation of Eosinopenia as a SIRS Biomarker in Critically Ill Horses.

Systemic inflammatory response syndrome (SIRS) is a very common finding in critically ill patients. To accurately identify patients with SIRS and those who need intensive care, several markers have been evaluated, including cortisol, WBC or lactate. It is widely known that a stress leukogram includes eosinopenia as one of its main markers (neutrophilia, eosinopenia, lymphopenia and mild monocytes). It is known that cortisol concentration in plasma is the main stress biomarker and is strongly correlated with the severity of disease in horses. However, it is not possible to measure this parameter routinely in clinical conditions. Hence, in this study it was hypothesized that the eosinophil count could be a reliable parameter to identify critically ill horses. Horses included in this study were divided into three groups: Group A (sick horses received at the Emergency Unit which did not fulfil the criteria for SIRS), Group B (horses that meet two or more criteria for inclusion in the definition of SIRS) and a control group of healthy horses. In this study, horses with SIRS showed lower eosinophil counts than healthy horses. Moreover, non-surviving horses exhibited lower eosinophil counts than survivors. Eosinopenia could be used to identify horses with SIRS and can be useful as a prognostic marker.

Predictors and risk factors for admission to critical care in cervicofacial infections: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infections carry significant morbidity. Patients present on a broad spectrum of severity, with some requiring outpatient management and others admission to higher level care. Recognition of risk factors is helpful in decision making regarding the need for admission to higher level care. Prospective data were captured on 1002 patients in 25 centres across 17 regions of the United Kingdom (UK) by the Maxillofacial Trainee Research Collaborative (MTReC). Patients admitted to critical care were compared with those who received ward-level care. Multivariate and receiver operating characteristic curve analyses were used to identify predictors for critical care admission. Our results show that the best predictor for critical care admission is the presence of three or more features of airway compromise (AUC 0.779), followed by C-reactive protein (CRP) >100 mg/L (OR 2.70; 95% CI 1.59 to 4.58; p < 0.005), submandibular space involvement (OR 3.82; 95% CI 1.870 to 7.81; p = 0.003), white cell count (WCC) >12 × 109/ dl (1.05; 95% CI 1.01 to 1.10; p = 0.03), and positive systemic inflammatory response syndrome criteria (OR 2.78; CI 1.35 to 5.80; p = 0.006). Admission to critical care is multifactorial, however, the presence of three or more features of airway compromise is the best predictor. Awareness of this alongside other key clinical findings in cervicofacial infections may allow for the early recognition of patients who may require escalation to critical care.

Acute Clinical Syndrome of HLH in Patients with Hematologic Malignancy and EBV Infection

Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a syndrome characterized by dysregulation of the reticuloendothelial system, overactivation of macrophages and lymphocytes, hemophagocytosis, and cytokine storm collectively causing systemic inflammation and organ damage. Malignancy-associated HLH (M-HLH) is associated with poor prognosis and survival of 1-2 months (Daver N, et.al., Cancer. 2017). Viral infections such as Epstein-Barr Virus (EBV) can independently contribute to development of lymphoproliferative neoplasms and non-malignancy associated HLH. While both malignancy and EBV are recognized as independent risk factors for HLH, a syndrome of overlapping M-HLH and EBV-HLH remains underreported. The optimal long-term treatment strategy for M-HLH in EBV positive patients is unknown, with combinations of HLH and malignancy directed therapy reported in the literature without significant improvement in survival (Zhao A, et.al., Front Immunol. 2022). We report a case series of patients with EBV infection and newly diagnosed hematologic malignancies complicated by HLH demonstrating poor prognosis despite initial control of disease. Methods: Between July 2020 and July 2021, 8 patients >18 years of age hospitalized at Montefiore Medical Center were identified meeting diagnostic criteria of HLH with associated primary hematologic malignancy, and concomitant EBV infection. Data on demographics and clinical characteristics, laboratory studies, malignancy diagnosis, treatments received, and disease course were collected. HLH-04, H-Score were recorded for all patients. Data were analyzed using descriptive statistics. Results: The median age was 53.6 years old (range 29-75). Five out of 8 patients met systemic inflammatory response syndrome (SIRS) criteria on presentation. The median H-Score was 217.1 (range 183-247). All but one patient exceeded CD25 and ferritin parameters of optimized HLH inflammatory (OHI) index suggestive of high mortality risk. Classical Hodgkin Lymphoma (cHL) was seen in 4/8 patients; other diagnoses included large B cell lymphoma, angioimmunoblastic T cell lymphoma, intravascular large B cell lymphoma, and anaplastic large cell lymphoma. Dexamethasone was the backbone of treatment and the initial HLH directed therapy in all patients, starting on average 9 days after presentation (range 2-17) and preceding treatment with other HLH directed therapies by median of 7.2 days (range 0-33). Four out of 8 patients received dexamethasone, etoposide, and rituximab; 2 patients received dexamethasone with etoposide and 2 received dexamethasone alone. The administration schedule and cumulative doses of both rituximab and etoposide varied significantly between the patients. Initiation of malignancy directed chemotherapy lagged the initiation of dexamethasone by median of 16.5 days (range 0-53). Delays were due to patients' clinical condition, organ function, and pending diagnosis of malignancy. Median overall survival from the initial presentation was 102.5 days (range 33-219). Two out of 8 patients in our case series survived. One received dexamethasone and etoposide, followed by 6 cycles of malignancy-directed chemotherapy and autologous stem cell transplant. The second patient was treated with dexamethasone, rituximab, etoposide with addition of anakinra, followed by malignancy directed therapy without rituximab or etoposide. At the time of death, 4 out of 6 patients had active HLH and 3 out of 6 patients were treated for an overwhelming polymicrobial infection. Conclusion: HLH is the setting of EBV-positive malignancy results in a syndrome with an aggressive clinical course and high early mortality rate. Here we demonstrate that HLH-directed therapy prior to or incorporated into malignancy-directed therapy extended patients' survival to median 3 months, as compared to 1-2 months reported in the literature. Nevertheless, most patients suffered HLH relapse and succumbed to infectious complications of prolonged hospitalization and immunosuppression. Long term HLH therapy with immunomodulatory agents and EBV-directed therapies is needed to achieve sustained control of systemic inflammation. Patients who survive initial HLH episode need to be closely monitored for recurrence. Preemptive strategies such as autologous stem cell transplant should be considered in eligible patients to further reduce the risk of relapse. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The progression of sepsis from physiologic systemic inflammatory response to immune dysregulation due to life-threatening infections

Sepsis was defined in 1991 by the systemic inflammatory response syndrome (SIRS) criteria which consisted mostly of physiologic responses to infection or inflammation (fever, tachycardia, tachypnea, and leukocytosis). These criteria were initially proposed to identify patients with gram-negative bloodstream infection (BSI). However, most patients with BSI are not critically ill at initial presentation using objective clinical scores for acute severity of illness, such as the Pitt bacteremia score (PBS). Lack of specificity and low positive predictive value (PPV) are other pitfalls of the SIRS criteria. Moreover, the implementation of sepsis interventions based on this outdated definition failed to improve patients’ outcomes and in some settings was associated with increased use of broad-spectrum antibiotics and Clostridioides difficile (C. difficile) infection. In 2016, sepsis was redefined as a dysregulatory host response to life-threatening infections using quick sequential organ failure assessment (qSOFA) score. The presence of two of three bedside clinical variables (hypotension, respiratory distress, and altered mental status) that have consistently predicted mortality in patients with infections now constitutes sepsis. The scientific debate continues in the medical literature regarding the performance of the new criteria. Some medical professionals and quality organizations consider these changes to the sepsis definition too revolutionary and are resistant to altering existing medical practice. This narrative review presents infection as a continuum from localized to systemic infection (pre-sepsis) with the potential progression into sepsis and septic shock if appropriate antibiotic therapy and source control are delayed. The review assesses host and microbial factors that may influence the rate of progression through the sepsis cascade and proposes diagnostic considerations and management decisions at each step of the way. It emphasizes the need to utilize precision medicine concepts in selecting empirical antibiotic therapy based on patient-specific risk factors for infections due to resistant bacteria and potential benefits from appropriate therapy across the sepsis spectrum.

Pediatric Sepsis: The Importance of Understanding Criteria for Diagnosis.

Pediatric sepsis is a very significant issue for the pediatric population. Sepsis can be defined in relation to systemic inflammatory response syndrome. It can be further characterized based on the severity, including severe sepsis, septic shock, multiorgan failure, and refractory septic shock, in the setting of proven infection or suspected infection. In the pediatric population, sepsis is a complicated and dangerous event with no one specific criteria or definition in the systemic inflammatory response syndrome criteria applicable to every child who is suffering from the condition. The goal of this paper is to enhance awareness of the various forms and severities of sepsis in the pediatric population so that swift diagnosis can be made and treatment can be initiated. An electronic literature review search was performed, and relevant data were collected from peer-reviewed articles from January 2005 to May 2020. The nonspecific nature of this condition can manifest as cardiovascular dysfunction, and hematologic abnormalities to neurologic symptoms, resulting in a late diagnosis, which ultimately leads to an increase in mortality and morbidity. The implications of sepsis in the pediatric population needs to be addressed. It is imperative for all medical professionals, including medical students, to understand the criteria and to raise a high level of suspicion when presented with a child exhibiting symptoms that may indicate sepsis. By increasing awareness of pediatric sepsis, complications, including death, that arise as a result of late diagnosis and treatment would be substantially decreased. [Pediatr Ann. 2022;51(10):e405-e408.].

Clinical Profile of Patients Presenting With Sepsis to the Emergency Department of a Tertiary Care Hospital in Wardha During the COVID Pandemic (June 2020-June 2021).

BackgroundSepsis is defined as life-threatening organ dysfunction due to a dysregulated host response to infection. Septic shock, multi-organ dysfunction, and death occur in severe cases with reduced blood flow to vital organs. Sepsis contributes to 15-20% of all global deaths. Through this study, we intend to evaluate the clinical profile and study the common blood investigatory panels along with organisms causing sepsis in patients presenting with sepsis in the emergency department during the COVID pandemic. In addition, the study was also done to estimate the prevalence of sepsis and compare patients having sepsis with serum lactate, sepsis with Systemic Inflammatory Response Syndrome (SIRS) criteria, and sepsis with quick Sepsis Related Organ Failure Assessment (qSOFA) score.MethodObservational retrospective study to evaluate patients presenting with sepsis diagnosed by the Third International Consensus Definitions for Sepsis and Septic Shock” criteria presenting to the emergency department of Acharya Vinoba Bhave Rural Hospital (AVBRH) affiliated to Jawaharlal Nehru Medical College (JNMC), Wardha during COVID pandemic (June 2020-June 2021).ResultsThe majority of the patients presented with fever (42%), and very few presented with altered mental status (8%). Seventy-four percent of the study population did not show any bacterial growth on blood culture, but out of the remaining 26%, blood culture, Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pnemoniae were the significant microbes. Amongst qSOFA, SIRS criteria, and serum lactate as a screening tool for sepsis, SIRS is the most sensitive for screening sepsis patients.ConclusionStaphylococcus aureus, Pseudomonas aerugenosa, and Klebsiella pneumoniae were the major contributors in the development of sepsis in COVID-19-associated infection. The presence of raised leukocyte counts and serum lactate should alarm clinicians of possible sources of infection. The timely initiation, rapid de-escalation of empirical antibiotics, and strict compliance with infection control practices should be accomplished to reduce the occurrence of multidrug resistance organisms.

Predicting Septic Shock After Emergent Ureteral Stenting in Stone-Related Obstruction and Presumed Infections.

Introduction: Systemic inflammatory response syndrome (SIRS) criteria have long been used to predict septic shock. The sequential organ failure assessment and quick sequential organ failure assessment (qSOFA) scores have been suggested to be more accurate predictors. This study aims to compare SIRS and qSOFA for predicting of septic shock in the setting of retrograde ureteral stenting for obstructing stones and concomitant urinary tract infection. Methods: A retrospective review of records at two centers of consecutive patients was performed. Patients with unilateral ureteral obstruction by a stone who underwent ureteral stent placement and suspicion of urinary tract infection were identified. Primary endpoints were SIRS and qSOFA positive scores, intensive care unit admission, and vasopressor requirements. Results: A total of 187 patients were included. SIRS criteria were met in 103 patients (55.1%) and in 30 patients who experienced septic shock. qSOFA criteria were met for 24 patients (12.8%) and in 18 patients who experienced septic shock. Specificity for postoperative septic shock was significantly higher for qSOFA than for SIRS criteria (75 vs 29.1%, McNemar test p < 0.001). Both SIRS and qSOFA had significant areas under the curve (AUC), qSOFA had a fair AUC of 0.750, p = 0.001, whereas SIRS had a poor AUC of 0.659, p = 0.008. Univariate logistic regression of SIRS and qSOFA for septic shock showed: qSOFA (odds ratio [OR] 46 [0.25-228], p = 0.001) and SIRS (OR 2.29 [0.716-7.37], p = 0.162). Conclusion: Although SIRS offers higher sensitivity, qSOFA score may offer advantages over SIRS criteria in evaluation of risk for septic shock for patients who present with obstructing ureteral stone and urinary tract infection.

A Historical Review of the Evolution of the Systemic Inflammatory Response Syndrome Criteria in the Diagnosis of Sepsis: Should it Continue to be Used and Could Nurses Have a More Prominent Role in Identifying Sepsis?

Despite a better understanding of the pathophysiology of sepsis as well as validation of clinical scoring systems for its prompt identification, current hospital computer-based algorithms depend on the use of the systemic inflammatory response syndrome (SIRS) criteria for the early diagnosis and management of sepsis. We present two clinical cases where strict adherence to these SIRS criteria resulted in significant delays to those patients, which prompted us to perform a historical review on the development of said SIRS criteria and the current recommendations regarding sepsis issued by multiple medical societies. Based on that, we believe there is, potentially, a more prominent role for nurses in identifying sepsis earlier and wondered whether SIRS criteria should continue to be used.

Advanced Triage Protocol: The Role of an Automated Lactate Order in Expediting Rapid Identification of Patients at Risk of Sepsis in the Emergency Department.

OBJECTIVES:We undertook a process improvement initiative to expedite rapid identification of potential sepsis patients based on triage chief complaint, vital signs, and initial lactate level.DESIGN:Prospective cohort study.SETTING:Seven hundred-bed tertiary care hospital with ≅65,000 patient visits/yr.PATIENTS:Patients presenting to emergency department (ED) triage who met the following criteria: greater than or equal to two of the three systemic inflammatory response syndrome criteria assessable in triage, a chief complaint suggestive of infection, emergency severity index 2 or 3, and ambulatory to ED.INTERVENTIONS:A computer-generated lactate order was created, staff education and resources increased, and point-of-care lactate testing was introduced.MEASUREMENTS AND MAIN RESULTS:Primary endpoints include the following: percent of patients having a lactate level drawn, percent of lactate samples resulting before room placement, and time intervals from triage to lactate blood draw and to lactate result. Secondary endpoints were percentage of patients admitted to the hospital, percentage admitted to the ICU, and in-hospital mortality. Six thousand nine hundred six patients were included: 226 historic controls (HCs) and 6,680 intervention group patients. The mean serum lactate level was 1.77 ± 1.18 mmol/L. The percentage of patients having a lactate resulted increased from 27.4% in the HC period to 79.6%. The percentage of these lactate results available while the patient was still in the waiting room increased from 0.4% during the HC period to 33.7% during Phase 5 (p < 0.0001). In the intervention period, time from triage to lactate result decreased (78.1–63.4 min; p < 0.0001) and time to treatment room decreased (59.3–39.6 min; p < 0.0001).CONCLUSIONS:Implementation of a computerized lactate order using readily available data obtained during ED triage, combined with point-of-care lactate testing, improves time to lactate blood draw and lactate result in patients at risk for severe sepsis. Initial lactate levels correlated with admission to the hospital, admission to the ICU, and in-hospital mortality.

Prognostic accuracy of SOFA and qSOFA for mortality among children with infection: a meta-analysis.

Age-adjusted Sequential Organ Failure Assessment (SOFA) and age-adjusted quick SOFA (qSOFA) scores have been developed to predict poor outcomes in children with infection. We investigated the prognostic performance of age-adjusted SOFA and age-adjusted qSOFA scores and compared them with the systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in children with infection. A bivariate random-effects regression model was used for synthesis of diagnostic test data. A total of 14 studies invoing 70,194 participants were included. The pooled sensitivity for age-adjusted SOFA, age-adjusted qSOFA, and SIRS were 0.82 (95% CI, 0.74-0.88), 0.46 (95% CI, 0.22-0.71), and 0.79 (95% CI, 0.66-0.88), respectively. The pooled specificity for age-adjusted SOFA, age-adjusted qSOFA, and SIRS were 0.62 (95% CI, 0.45-0.77), 0.90 (95% CI, 0.66-0.98), and 0.39 (95% CI, 0.26-0.54), respectively. The area under the summary receiver operating characteristic curve (AUSROC) for age-adjusted SOFA, age-adjusted qSOFA, and SIRS were 0.82 (95% CI, 0.79-0.85), 0.66 (95% CI, 0.62-0.70), and 0.64 (95% CI, 0.60-0.68), respectively. Different baseline populations, different SOFA adaptation methods and different cut-offs used for age-adjusted SOFA may be potential sources of heterogeneity. Age adjusted SOFA score is a useful tool for predicting mortality in children with sepsis/suspected sepsis. First study to investigate the prognostic performance of age-adjusted sequential organ failure assessment (SOFA) and age adjusted quick SOFA (qSOFA) scores in comparison to the systemic inflammatory response criteria (SIRS) for the prediction of mortality in children with sepsis. The age-adjusted SOFA score predicts poor outcomes with high sensitivity in children with sepsis Low sensitivity limits the utility of age-adjusted qSOFA as a simple predictive tool for adverse outcomes. Developing another enhanced or modified bedside tool with higher sensitivity may be necessary.

The Presence of Bacteremia Indicates Higher Inflammatory Response and Augments Disease Severity in Adult Patients with Urinary Tract Infections.

Background: This study investigated the association between the presence of bacteremia and increase in the requirement for intensive care in adult patients with urinary tract infection (UTI). The study also analyzed the differences in clinical features between patients with versus without bacteremia. Methods: We conducted a retrospective screening of the medical records of adult patients admitted during a 4-month period at a single medical center. We excluded patients with concomitant infections and patients whose urine and blood samples were not collected in the emergency department (ED). The included patients were allocated to two groups—bacteremia and nonbacteremia groups—according to the blood culture results for samples collected in the ED. Results: The study cohort comprised 637 patients, including 158 (24.8%) patients in the bacteremia group and 479 (75.2%) patients in the nonbacteremia group. Compared with the patients in the nonbacteremia group, those in the bacteremia group satisfied more systemic inflammatory response syndrome (SIRS) criteria; they had a higher white cell count, C-reactive protein level, and sequential organ failure assessment (SOFA) scores; and had a greater requirement for intensive care (bacteremia vs. nonbacteremia; SIRS: 79.1% vs. 49.9%, p = 0.000; leukocytosis: 68.2% vs. 57.6%, p = 0.000; elevation of CRP: 96.2% vs. 78.6%, p = 0.000; SOFA: 39.2% vs. 23.2%, p = 0.000; requirement for intensive care: 13.9% vs. 4.4%, p = 0.000, respectively). According to the results of multivariate logistic regression, bacteremia and sepsis were independent factors associated with the requirement for intensive care. Conclusions: Bacteremia increased the requirement for intensive care in patients with UTI. Physicians can identify bacteremia using inflammatory markers, the SIRS criteria, and SOFA scores.

Evaluation of quick sequential organ failure scores in dogs with severe sepsis and septic shock.

To evaluate the prognostic utility of the quick sequential organ failure assessment score indogs with severe sepsis and septic shock presenting to an emergency service, and evaluate the clinical value of the quick sequential organ failure assessment score to predict severe sepsis and septic shock. The quick sequential organ failure assessment score was calculated by evaluating respiratory rate (&gt;22 breaths per minute), arterial systolic blood pressure (≤100 mmHg) and altered mentation. The quick sequential organ failure assessment scores with respiratory rate cut-offs of greater than 22, greater than 30 and greater than 40 were compared. Cases were defined as dogs presented to the emergency room and met at least 2 systemic inflammatory response syndrome criteria, had documented infection, and at least one organ dysfunction. A control population of dogs included animals with non-infectious systemic inflammatory response syndrome. Forty-five dogs with severe sepsis and septic shock and 45 dogs with non-infectious systemic inflammatory response syndrome were included in the final analysis. The quick sequential organ failure assessment provided poor discrimination between survivors and non-survivors for severe sepsis and septic shock (area under receiving operating characteristic curve, 0.51; 95% confidence interval, 0.35 to 0.67). Discrimination remained poor when quick sequential organ failure assessment greater than 30 and quick sequential organ failure assessment greater than 40 scores were calculated (area under receiving operating characteristic curve, 0.56; 95% confidence interval, 0.39 to 0.72, and 0.54; 95% confidence interval, 0.36 to 0.71). The quick sequential organ failure assessment of at least 2, quick sequential organ failure assessment greater than 30 of at least 2 and quick sequential organ failure assessment greater than 40 of at least 2 produced sensitivity and specificity to detect severe sepsis and septic shock of 66.7% and 64.5%, 62.2% and 71.1%, 44.4% and 80%, respectively. Scoring systems utilised in emergency rooms should have high sensitivity to reduce missed sepsis cases and treatment delays. The use of the quick sequential organ failure assessment for severe sepsis and septic shock demonstrated poor mortality prediction and low sensitivity to detect canine patients with severe sepsis and septic shock and should not be used alone when screening for sepsis.

Accuracy of Quick Sequential Organ Failure Assessment Score & Systemic Inflammatory Response Syndrome Criteria in Predicting Adverse Outcomes in Emergency Surgical Patients With Suspected Sepsis: A Prospective Observational Study.

Purpose: Due to the mixed population enrolled in different studies i.e., medical and surgical cases, conflicting data exists about the accuracy of quick sequential organ failure assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores in predicting adverse outcomes in patients with suspected sepsis presenting to the surgical emergency.Method: A prospective observational study was done in the department of surgery of a tertiary teaching hospital, India from June 2018 to July 2019. Consecutive patients who visited the surgical emergency department with suspected sepsis were included. Patients were followed up until hospital discharge or death.Results: Of the 410 patients screened, 287 were included in the analysis. The median age was 52 years (interquartile range, 41 to 61years) and 208 (72.8%) were men. Around 56.8% of patients had intra-abdominal pathology, and 43.2% had skin and soft -tissue infection. Sixty-nine (24%) patients died during their hospitalization, 98 (34.1%) patients had organ dysfunction, and 168 (58.5%) patients needed admission to the intensive care unit (ICU). A higher qSOFA score (≥2) was associated with organ dysfunction, ICU admission, and in-hospital mortality. The specificity, positive predictive value and diagnostic accuracy of qSOFA for organ dysfunction (85.7%, 67.8%, 76.3%), ICU admission (92.4%, 89.3%, 64.5%), and in-hospital mortality (81.6%, 52.4%, 77.4%) was higher than SIRS. The area under the receiver operating characteristic curve for qSOFA for these variables was also higher than for SIRS (0.826 vs. 0.524, 0.823 vs. 0.577, and 0.823 vs. 0.555, respectively).Conclusion: qSOFA is a better model for predicting adverse outcomes and mortality, organ dysfunction, and ICU admission in surgical patients. However, SIRS indicates intervention requirements in a surgical patient better than qSOFA.

Pediatric Emergency Department Sepsis Screening Tool Accuracy During the COVID-19 Pandemic.

Automated sepsis alerts in pediatric emergency departments (EDs) can identify patients at risk for sepsis, allowing for earlier intervention with appropriate therapies. The impact of the COVID-19 pandemic on the performance of pediatric sepsis alerts is unknown. We performed a retrospective cohort study of 59 335 ED visits before the pandemic and 51 990 ED visits during the pandemic in an ED with an automated sepsis alert based on systemic inflammatory response syndrome criteria. The sensitivity, specificity, negative predictive value, and positive predictive value of the sepsis algorithm were compared between the prepandemic and pandemic phases and between COVID-19-negative and COVID-19-positive patients during the pandemic phase. The proportion of ED visits triggering a sepsis alert was 7.0% (n = 4180) before and 6.1% (n = 3199) during the pandemic. The number of sepsis alerts triggered per diagnosed case of hypotensive septic shock was 24 in both periods. There was no difference in the sensitivity (74.1% vs 72.5%), specificity (93.2% vs 94.0%), positive predictive value (4.1% vs 4.1%), or negative predictive value (99.9% vs 99.9%) of the sepsis alerts between these periods. The alerts had a lower sensitivity (60% vs 73.3%) and specificity (87.3% vs 94.2%) for COVID-19-positive versus COVID-19-negative patients. The sepsis alert algorithm evaluated in this study did not result in excess notifications and maintained adequate performance during the COVID-19 pandemic in the pediatric ED setting.