Improving the diagnosis and prognosis of sepsis according to the sources of infection.

INTRODUCTION: The clinical presentation of sepsis is heterogeneous and largely depends on the primary site of infection. Currently, factors associated with sepsis outcomes do not differentiate between infection sites. The objective of this investigation was to identify variables associated with risk of in-hospital mortality or intensive care unit (ICU) admission, according to infection sites. METHODS: This was a secondary analysis of a multicentre prospective cohort of ED patients ≥18 years old from three university hospitals in Medellín, Colombia. Multivariable logistic regression models were performed to estimate the association of factors with in-hospital mortality or ICU admission according to five infection sites: urinary tract infection (UTI), community-acquired pneumonia (CAP), intra-abdominal infection, sepsis without evident source (primary) and other sites. RESULTS: The infection sites of the 1947 patients included were: UTI (n=586), CAP (n=585), intra-abdominal infection (n=213), primary (n=224) and other sites (n=339). In the multivariable model, the factors associated with in-hospital mortality or ICU admission varied by infection site: respiratory rate (RR), systolic blood pressure (SBP) and lactate for UTI; heart rate (HR), RR and temperature <38°C for CAP; Glasgow Coma Scale (GCS), lactate and age <65 for intra-abdominal infection; SBP, GCS, lactate and temperature <38°C for primary and RR, GCS and temperature <38°C for other. CONCLUSIONS: Our results suggest that the diagnosis and prognosis of sepsis in emergency care should consider different clinical criteria, based on site of infection. Given the heterogeneity and interindividual variability of sepsis, a more individualised approach could help to direct treatment, monitor response and facilitate initial clinical decisions.

Supervised classification techniques for prediction of mortality in adult patients with sepsis.

BACKGROUND: Sepsis mortality is still unacceptably high and an appropriate prognostic tool may increase the accuracy for clinical decisions. OBJECTIVE: To evaluate several supervised techniques of Artificial Intelligence (AI) for classification and prediction of mortality, in adult patients hospitalized by emergency services with sepsis diagnosis. METHODS: Secondary data analysis of a prospective cohort in three university hospitals in Medellín, Colombia. We included patients >18 years hospitalized for suspected or confirmed infection and any organ dysfunction according to the Sepsis-related Organ Failure Assessment. The outcome variable was hospital mortality and the prediction variables were grouped into those related to the initial clinical treatment and care or to the direct measurement of physiological disturbances. Four supervised classification techniques were analyzed: the C4.5 Decision Tree, Random Forest, artificial neural networks (ANN) and support vector machine (SVM) models. Their performance was evaluated by the concordance between the observed and predicted outcomes and by the discrimination according to AUC-ROC. RESULTS: A total of 2510 patients with a median age of 62 years (IQR = 46-74) and an overall hospital mortality rate of 11.5% (n = 289). The best discrimination was provided by the SVM and ANN using physiological variables, with an AUC-ROC of 0.69 (95%CI: 0.62; 0.76) and AUC-ROC of 0.69 (95%CI: 0.61; 0.76) respectively. CONCLUSION: Deep learning and AI are increasingly used as support tools in clinical medicine. Their performance in a syndrome as complex and heterogeneous as sepsis may be a new horizon in clinical research. SVM and ANN seem promising for improving sepsis classification and prognosis.

Biomarkers as a Prognostic Factor in COPD Exacerbation: A Cohort Study.

The acute exacerbations of COPD (AECOPD) are one of the main causes of hospitalization and morbimortality in the adult population. There are not many tools available to predict the clinical course of these patients during exacerbations. Our goal was to estimate the clinical utility of C Reactive Protein (CRP), Mean Platelet Volume (MPV), eosinophil count and neutrophil/lymphocyte ratio (NLR) as in-hospital prognostic factors in patients with AECOPD. A prospective cohort study was conducted in patients who consulted three reference hospitals in the city of Medellín for AECOPD and who required hospitalization between 2017 and 2020. A multivariate analysis was performed to estimate the effect of biomarkers in the two primary outcomes: the composite outcome of in-hospital death and/or admission to the ICU and hospital length-of-stay. A total of 610 patients with a median age of 74 years were included; 15% were admitted to the ICU and 3.9% died in the hospital. In the multivariate analysis adjusted for confounding variables, the only marker significantly associated with the risk of dying or being admitted to the ICU was the NLR > 5 (OR: 3; CI95%: 1.5; 6). Similarly, the NLR > 5 was also associated to a lower probability of being discharged alive from the institution (SHR: 0.73; CI95%: 0.57; 0.94) and, therefore, a longer hospital stay. It was found that a neutrophil/lymphocyte ratio greater than 5 is a strong predictor of mortality or ICU admissions and a longer hospital stay in patients hospitalized with AECOPD.

Community-acquired pneumonia: comparison of three mortality prediction scores in the emergency department.

Background: qSOFA is a score to identify patients with suspected infection and risk of complications. Its criteria are like those evaluated in prognostic scores for pneumonia (CRB-65 - CURB-65), but it is not clear which is best for predicting mortality and admission to the ICU. Objective: Compare three scores (CURB-65, CRB-65 and qSOFA) to determine the best tool to identify emergency department patients with pneumonia at increased risk of mortality or intensive care unit (ICU) admission. Methods: Secondary analysis of three prospective cohorts of patients hospitalized with diagnosis of pneumonia in five Colombian hospitals. Validation and comparison of the score´s accuracies were performed by means of discrimination and calibration measures. Results: Cohorts 1, 2 and 3 included 158, 745 and 207 patients, with mortality rates of 32.3%, 17.2% and 18.4%, and admission to ICU was required for 52.5%, 43.5% and 25.6%, respectively. The best AUC-ROC for mortality was for CURB-65 in cohort 3 (AUC-ROC=0.67). The calibration was adequate (p>0.05) for the three scores. Conclusions: None of these scores proved to be an appropriate predictor for mortality and admission to the ICU. Furthermore, the CRB 65 exhibited the lowest discriminative ability.

Introducción: el qSOFA es un nuevo puntaje propuesto para ayudar a identificar pacientes con sospecha de infección y con alta probabilidad de desarrollar complicaciones graves. Los criterios del qSOFA son similares a los evaluados en los puntajes de pronóstico usados tradicionalmente en neumonía (CRB-65 y CURB-65), pero no está claro cuál es mejor para predecir la mortalidad y la admisión a la UCI en pacientes con neumonía en el servicio de urgencias. Objetivo: comparar tres puntajes (CURB-65, CRB-65 y qSOFA) para determinar la mejor herramienta para identificar en servicios de urgencias a los pacientes con neumonía con mayor riesgo de mortalidad o ingreso en la unidad de cuidados intensivos (UCI). Métodos: análisis secundario de datos de tres estudios de cohorte prospectivos con pacientes atendidos por urgencias con diagnóstico de neumonía en 5 hospitales de Colombia. Se realizó validación y comparación de la exactitud de los puntajes por medio de medidas de discriminación y de calibración. Resultados: las cohortes 1, 2 y 3 incluyeron 158, 745 y 207 pacientes, con mortalidad de 32.3%, 17.2% y 18.4%, respectivamente. Se requirió la admisión a la UCI para 52.5%, 43.5% y 25.6% pacientes3, respectivamente. La mejor AUC-ROC para mortalidad fue para CURB-65 en la cohorte 3 (AUC-ROC= 0.67). La calibración de los modelos fue adecuada para los tres puntajes (P>0.05). Conclusiones: Ninguno de estos puntajes demostró ser un predictor adecuado de mortalidad e ingreso en UCI. Además, el CRB 65 mostró la capacidad discriminativa más baja.

Antimicrobials administration time in patients with suspected sepsis: is faster better? An analysis by propensity score.

BACKGROUND: Early use of antimicrobials is a critical intervention in the treatment of patients with sepsis. The exact time of initiation is controversial and its early administration may be a difficult task in crowded emergency departments (ED). The aim of this study was to estimate, using a matched propensity score, the effect on hospital mortality of administration of antimicrobials within 1 or 3 hours, in patients admitted to the ED with sepsis. METHODS: This was a secondary analysis of a multicenter prospective cohort. Patients included in the study were older than 18 years, hospitalized between 2014 and 2016 with suspected sepsis, and admitted to ED of three tertiary care university hospitals in Medellín, Colombia. A propensity score analysis for administration of antimicrobials, both within 1 and 3 h of admission by the ED, was fitted with 28 variables related with clinical attention and physiological changes. As a sensitivity analysis, a logistic regression model was fitted for antimicrobial use adjusted both by propensity score and confounding variables. RESULTS: The study cohort was composed of 2454 patients with a median age of 62 years (IQR = 46-74). Among them, 32% (n = 781) received antibiotics within 3 h and 14% (n = 340) within the first hour. The main diagnoses were urinary tract infection (28%, n = 682) and pneumonia (27%, n = 671). Blood cultures were obtained in 87% (n = 2140) and yielded positive in 29% (n = 629), mainly with Escherichia coli (37%, n = 230), Staphylococcus aureus (21%, n = 132), and Klebsiella pneumoniae (10.2%, n = 64). The hospital mortality rate was 11.5% (n = 283). There were no significant differences in mortality, after adjustment, using antimicrobials either in the first hour (OR 1.03; 95% CI = 0.63; 1.70) or 3 h (OR 0.85; 95% CI = 0.61; 1.20). There were no changes with different models for sensitivity analysis. CONCLUSIONS: Despite the obvious constraints given for sample size and residual confounding, our results suggest that we need a more comprehensive approach to sepsis and its treatment, considering early detection, multiple interventions, and goals beyond the simple time-to-antimicrobials.

Author's response to letter "Antimicrobials administration time in patients with suspected sepsis: faster is better for severe patients".

We are appreciative to Dr. Jouffroy and Pr. Vivien for their responses and insights, and we agree with their words about the controversial aspect timing to antibiotic administration. Nevertheless, we stand firmly that it is not just about the time of administration of antimicrobials, but the early recognition and the comprehensive approach to recognize the most severe patients.

Association between site of infection and in-hospital mortality in patients with sepsis admitted to emergency departments of tertiary hospitals in Medellin, Colombia. / Asociación entre el sitio de infección y la mortalidad hospitalaria en pacientes con sepsis atendidos en urgencias de hospitales de tercer nivel en Medellín, Colombia.

OBJECTIVE: To determine the association between the primary site of infection and in-hospital mortality as the main outcome, or the need for admission to the intensive care unit as a secondary outcome, in patients with sepsis admitted to the emergency department. METHODS: This was a secondary analysis of a multicenter prospective cohort. Patients included in the study were older than 18 years with a diagnosis of severe sepsis or septic shock who were admitted to the emergency departments of three tertiary care hospitals. Of the 5022 eligible participants, 2510 were included. Multiple logistic regression analysis was performed for mortality. RESULTS: The most common site of infection was the urinary tract, present in 27.8% of the cases, followed by pneumonia (27.5%) and intra-abdominal focus (10.8%). In 5.4% of the cases, no definite site of infection was identified on admission. Logistic regression revealed a significant association between the following sites of infection and in-hospital mortality when using the urinary infection group as a reference: pneumonia (OR 3.4; 95%CI, 2.2 - 5.2; p < 0.001), skin and soft tissues (OR 2.6; 95%CI, 1.4 - 5.0; p = 0.003), bloodstream (OR 2.0; 95%CI, 1.1 - 3.6; p = 0.018), without specific focus (OR 2.0; 95%CI, 1.1 - 3.8; p = 0.028), and intra-abdominal focus (OR 1.9; 95%CI, 1.1 - 3.3; p = 0.024). CONCLUSIONS: There is a significant association between the different sites of infection and in-hospital mortality or the need for admission to an intensive care unit in patients with sepsis or septic shock. Urinary tract infection shows the lowest risk, which should be considered in prognostic models of these conditions.

OBJETIVO: Determinar en pacientes con sepsis admitidos en el servicio de urgencias la asociación entre el foco infeccioso principal y la mortalidad intrahospitalaria como desenlace principal o requerimiento de ingreso a unidad de cuidados intensivos como desenlace secundario. MÉTODOS: Análisis secundario de cohorte prospectiva multicéntrica. Se incluyeron pacientes mayores de 18 años con diagnóstico de sepsis grave o choque séptico atendidos en las salas de urgencias de 3 hospitales de alta complejidad. De 5022 elegibles, se incluyeron 2510 participantes. Análisis de regresión logística múltiple para mortalidad. RESULTADOS: El sitio de infección más frecuente fue tracto urinario, presente en el 27,8% de los casos, seguido de neumonía en el 27,5% y foco intraabdominal en el 10,8%. En el 5,4% de los casos no se identificó foco claro al ingreso. Mediante regresión logística se encontró asociación significativa entre los siguientes sitios de infección y mortalidad intrahospitalaria al tomar como referencia el grupo de infección urinaria: neumonía (OR 3,4; IC95%, 2,2 - 5,2; p < 0,001), piel y tejidos blandos (OR 2,6; IC95%, 1,4 - 5,0; p = 0,003), torrente sanguíneo (OR 2,0; IC95%, 1,1 - 3,6; p = 0,018), sin foco claro (OR 2,0; IC95%, 1,1 - 3,8; p = 0,028), e intraabdominal (OR 1,9; IC95%, 1,1 - 3,3; p = 0,024). CONCLUSIONES: Existe una asociación significativa entre los diferentes sitios de infección y la mortalidad intrahospitalaria o requerimiento de unidad de cuidados intensivos en pacientes con sepsis o choque séptico, siendo la infección de vías urinarias la que confiere el menor riesgo, lo que se deberá tener en cuenta en los modelos pronósticos de estas condiciones.

Association of Clinical Hypoperfusion Variables With Lactate Clearance and Hospital Mortality.

BACKGROUND: Lactate has shown utility in assessing the prognosis of patients admitted to the hospital with confirmed or suspected shock. Some findings of the physical examination may replace it as screening tool. We have determined the correlation and association between clinical perfusion parameters and lactate at the time of admission; the correlation between the change in clinical parameters and lactate clearance after 6 and 24 h of resuscitation; and the association between clinical parameters, lactate, and mortality. METHODS: Prospective cohort study of adult patients hospitalized in the emergency room with infection, polytrauma, or other causes of hypotension. We measured serum lactate, capillary refill time, shock index, and pulse pressure at 0, 6, and 24 h after admission. A Spearman's correlation was performed between clinical variables and lactate levels, as well as between changes in clinical parameters and lactate clearance. The operative characteristics of these variables were determined by area under the receiver operating characteristic curve analysis and the association between lactate, clinical variables, and mortality through logistic regression. RESULTS: A total of 1,320 patients met the inclusion criteria, 66.7% (n = 880) confirmed infection, 19% (n = 251) polytrauma, and 14.3% (n = 189) another etiology. No significant correlation was found between any clinical variable and lactate values (r < 0.28). None of the variable had an adequate discriminatory capacity to detect hyperlactatemia (AUC < 0.62). In the multivariate model, lactate value at admission was the only variable independently associated with mortality (OR 1.2; 95% CI = 1.1-1.1). CONCLUSIONS: Among patients with hypoperfusion risk or shock, no correlation was found between clinical variables and lactate. Of the set of parameters collected, lactate at admission was the only independent marker of mortality.

Antibiotics has more impact on mortality than other early goal-directed therapy components in patients with sepsis: An instrumental variable analysis.

PURPOSE: To estimate the effect of each of the EGDT components, as well as of the antibiotics, on length-of-stay and mortality. METHODS: Prospective cohort in three hospitals. Adult patients admitted by the Emergency Rooms (ER) with infection and any of systolic blood pressure < 90 mmHg or lactate >4 mmol/L. An instrumental analysis with hospital of admission as the instrumental variable was performed to estimate the effect of each intervention on hospital mortality and secondary outcomes. RESULTS: Among 2587 patients evaluated 884 met inclusion criteria, with a hospital mortality rate of 17% (n = 150). In the instrumental analysis, the only intervention associated with an absolute reduction in mortality (21%) was the use of antibiotics in the first 3 h. In patients with lactate values ≥4 mmol/L in the ER, a non-decrease of at least 10% at six hours was independently associated with mortality (OR = 3.1; 95%CI = 1.5-6.2). CONCLUSIONS: Among patients entering ER with infection and shock or hypoperfusion criteria, the use of appropriate antibiotics in the first 3 h is the measure that has the greatest impact on survival. In addition, among patients with hyperlactatemia >4 mmol/L, the clearance of >10% of lactate during resuscitation is associated with better outcomes.

Community-acquired pneumonia: comparison of three mortality prediction scores in the emergency department / Neumonía adquirida en la comunidad: comparación de tres puntuaciones de predicción de mortalidad en el servicio de urgencias

Abstract Background: qSOFA is a score to identify patients with suspected infection and risk of complications. Its criteria are like those evaluated in prognostic scores for pneumonia (CRB-65 - CURB-65), but it is not clear which is best for predicting mortality and admission to the ICU. Objective: Compare three scores (CURB-65, CRB-65 and qSOFA) to determine the best tool to identify emergency department patients with pneumonia at increased risk of mortality or intensive care unit (ICU) admission. Methods: Secondary analysis of three prospective cohorts of patients hospitalized with diagnosis of pneumonia in five Colombian hospitals. Validation and comparison of the score´s accuracies were performed by means of discrimination and calibration measures. Results: Cohorts 1, 2 and 3 included 158, 745 and 207 patients, with mortality rates of 32.3%, 17.2% and 18.4%, and admission to ICU was required for 52.5%, 43.5% and 25.6%, respectively. The best AUC-ROC for mortality was for CURB-65 in cohort 3 (AUC-ROC=0.67). The calibration was adequate (p>0.05) for the three scores. Conclusions: None of these scores proved to be an appropriate predictor for mortality and admission to the ICU. Furthermore, the CRB 65 exhibited the lowest discriminative ability.

RESUMEN Introducción: el qSOFA es un nuevo puntaje propuesto para ayudar a identificar pacientes con sospecha de infección y con alta probabilidad de desarrollar complicaciones graves. Los criterios del qSOFA son similares a los evaluados en los puntajes de pronóstico usados tradicionalmente en neumonía (CRB-65 y CURB-65), pero no está claro cuál es mejor para predecir la mortalidad y la admisión a la UCI en pacientes con neumonía en el servicio de urgencias Objetivo: comparar tres puntajes (CURB-65, CRB-65 y qSOFA) para determinar la mejor herramienta para identificar en servicios de urgencias a los pacientes con neumonía con mayor riesgo de mortalidad o ingreso en la unidad de cuidados intensivos (UCI). Métodos: análisis secundario de datos de tres estudios de cohorte prospectivos con pacientes atendidos por urgencias con diagnóstico de neumonía en 5 hospitales de Colombia. Se realizó validación y comparación de la exactitud de los puntajes por medio de medidas de discriminación y de calibración. Resultados: las cohortes 1, 2 y 3 incluyeron 158, 745 y 207 pacientes, con mortalidad de 32.3%, 17.2% y 18.4%, respectivamente. Se requirió la admisión a la UCI para 52.5%, 43.5% y 25.6% pacientes3, respectivamente. La mejor AUC-ROC para mortalidad fue para CURB-65 en la cohorte 3 (AUC-ROC= 0.67). La calibración de los modelos fue adecuada para los tres puntajes (P>0.05). Conclusiones: Ninguno de estos puntajes demostró ser un predictor adecuado de mortalidad e ingreso en UCI. Además, el CRB 65 mostró la capacidad discriminativa más baja.

[Development and validation of a predictive model for bacteremia in patients hospitalized by the emergency department with suspected infection]. / Desarrollo y validación de un modelo predictor para bacteriemia en pacientes hospitalizados por el servicio de urgencias con sospecha de infección.

BACKGROUND: Positive blood cultures usually indicate disseminated infection that is associated with a poor prognosis and higher mortality. We seek to develop and validate a predictive model to identify factors associated with positive blood cultures in emergency patients. METHODS: Secondary analysis of data from two prospective cohorts (EPISEPSIS: developing cohort, and DISEPSIS: validation cohort) of patients with suspected or confirmed infection, assembled in emergency services in 10 hospitals in four cities in Colombia between September 2007 and February 2008. A logistic multivariable model was fitted to identify clinical and laboratory variables predictive of positive blood culture. RESULTS: We analyzed 719 patients in developing and 467 in validation cohort with 32% and 21% positive blood cultures, respectively. The final predictive model included variables with significant coefficients for both cohorts: temperature > 38° C, Glasgow < 15 and platelet < 150.000 cells/mm³, with calibration (goodness-of-fit H-L) p = 0.0907 and p = 0.7003 and discrimination AUC = 0.68 (95% CI = 0.65-0.72) and 0.65 (95% CI = 0.61-0.70) in EPISEPSIS and DISEPSIS, respectively. Specifically, temperature > 38 °C and platelets < 150.000 cells/mm³ and normal Glasgow; or Glasgow < 15 with normal temperature and platelets exhibit a LR between 1,9 (CI 95% = 1,2-3,1) and 2,3 (CI 95% = 1,7-3,1). Glasgow < 15 with any of low platelets or high temperature shows a LR between 2,2 (CI 95% = 1,1-4,4) and 2,6 (CI 95% = 1,7-4,3). DISCUSSION: Temperature > 38° C, platelet count < 150,000 cells/mm³ and GCS < 15 are variables associated with increased likelihood of having a positive blood culture.

Impact of immunohistochemistry-based molecular subtype on chemosensitivity and survival in Hispanic breast cancer patients following neoadjuvant chemotherapy.

BACKGROUND: Neoadjuvant chemotherapy (NAC) is the standard treatment for patients with locally advanced breast cancer, showing improvement in disease-free survival (DFS) and overall survival (OS) rates in patients achieving pathological complete response (pCR). The relationship between immunohistochemistry-based molecular subtyping (IMS), chemo sensitivity and survival is currently a matter of interest. We explore this relationship in a Hispanic cohort of breast cancer patients treated with NAC. METHODS: A retrospective survival analysis was performed on Colombian females with breast cancer treated at Instituto de Cancerología-Clinica Las Américas between January 2009 and December 2011. Patients were classified according to immunohistochemistry-based subtyping into the following five groups: Luminal A, Luminal B, Luminal B/HER 2+, HER2-enriched, and triple-negative breast cancer. Demographic characteristics, recurrence pattern, and survival rate were reviewed by bivariate and multivariate analysis. RESULTS: A total of 328 patients fulfilled the study's inclusion parameters and the distribution of subtypes were as follows: Luminal A: 73 (22.3%), Luminal B/HER2-: 110 (33.5%), Luminal B/HER2+: 75 (22.9%), HER2-enriched: 30 (9.1%), and triple-negative: 40 (12.2%). The median follow-up was 41 months (interquartile range: 31-52). Pathological response to NAC was as follows: complete pathological response (pCR) in 28 (8.5%) patients, partial 247 (75.3%); stable disease 47 (14.3%), and progression 6 (1.8%) patients. The presence of pCR had a significant DFS and OS in the entire group (p = 0.01) but subtypes had different DFS in Luminal B (p = 0.01) and triple negative (p = 0.02) and also OS in Luminal B (p = 0.01) and triple negative (p = 0.01). CONCLUSIONS: pCR is associated with an improved overall survival and disease-free survival rates in this group of Hispanics patients. Advanced stages, Luminal B subtypes, triple-negative tumours and non-pCR showed lower DFS.

Asociación entre el sitio de infección y la mortalidad hospitalaria en pacientes con sepsis atendidos en urgencias de hospitales de tercer nivel en Medellín, Colombia / Association between site of infection and in-hospital mortality in patients with sepsis admitted to emergency departments of tertiary hospitals in Medellin, Colombia

RESUMEN Objetivo: Determinar en pacientes con sepsis admitidos en el servicio de urgencias la asociación entre el foco infeccioso principal y la mortalidad intrahospitalaria como desenlace principal o requerimiento de ingreso a unidad de cuidados intensivos como desenlace secundario. Métodos: Análisis secundario de cohorte prospectiva multicéntrica. Se incluyeron pacientes mayores de 18 años con diagnóstico de sepsis grave o choque séptico atendidos en las salas de urgencias de 3 hospitales de alta complejidad. De 5022 elegibles, se incluyeron 2510 participantes. Análisis de regresión logística múltiple para mortalidad. Resultados: El sitio de infección más frecuente fue tracto urinario, presente en el 27,8% de los casos, seguido de neumonía en el 27,5% y foco intraabdominal en el 10,8%. En el 5,4% de los casos no se identificó foco claro al ingreso. Mediante regresión logística se encontró asociación significativa entre los siguientes sitios de infección y mortalidad intrahospitalaria al tomar como referencia el grupo de infección urinaria: neumonía (OR 3,4; IC95%, 2,2 - 5,2; p < 0,001), piel y tejidos blandos (OR 2,6; IC95%, 1,4 - 5,0; p = 0,003), torrente sanguíneo (OR 2,0; IC95%, 1,1 - 3,6; p = 0,018), sin foco claro (OR 2,0; IC95%, 1,1 - 3,8; p = 0,028), e intraabdominal (OR 1,9; IC95%, 1,1 - 3,3; p = 0,024). Conclusiones: Existe una asociación significativa entre los diferentes sitios de infección y la mortalidad intrahospitalaria o requerimiento de unidad de cuidados intensivos en pacientes con sepsis o choque séptico, siendo la infección de vías urinarias la que confiere el menor riesgo, lo que se deberá tener en cuenta en los modelos pronósticos de estas condiciones.

ABSTRACT Objective: To determine the association between the primary site of infection and in-hospital mortality as the main outcome, or the need for admission to the intensive care unit as a secondary outcome, in patients with sepsis admitted to the emergency department. Methods: This was a secondary analysis of a multicenter prospective cohort. Patients included in the study were older than 18 years with a diagnosis of severe sepsis or septic shock who were admitted to the emergency departments of three tertiary care hospitals. Of the 5022 eligible participants, 2510 were included. Multiple logistic regression analysis was performed for mortality. Results: The most common site of infection was the urinary tract, present in 27.8% of the cases, followed by pneumonia (27.5%) and intra-abdominal focus (10.8%). In 5.4% of the cases, no definite site of infection was identified on admission. Logistic regression revealed a significant association between the following sites of infection and in-hospital mortality when using the urinary infection group as a reference: pneumonia (OR 3.4; 95%CI, 2.2 - 5.2; p < 0.001), skin and soft tissues (OR 2.6; 95%CI, 1.4 - 5.0; p = 0.003), bloodstream (OR 2.0; 95%CI, 1.1 - 3.6; p = 0.018), without specific focus (OR 2.0; 95%CI, 1.1 - 3.8; p = 0.028), and intra-abdominal focus (OR 1.9; 95%CI, 1.1 - 3.3; p = 0.024). Conclusions: There is a significant association between the different sites of infection and in-hospital mortality or the need for admission to an intensive care unit in patients with sepsis or septic shock. Urinary tract infection shows the lowest risk, which should be considered in prognostic models of these conditions.

Lactate clearance: prognostic mortality marker in trauma patients / La depuración de lactato: marcador pronóstico de mortalidad en pacientes traumatizados

Abstract Introduction: High lactate values are associated with adverse outcomes in almost all clinical situations, lactate levels above 2 mmol/L are proposed as an early and reliable marker of tissue hypoperfusion, and lactate clearance during treatment has also been proposed during resuscitation as a prognostic factor. Objective: To determine the association between the initial value of lactate and its clearance after 6 and 24 hours in trauma patients with mortality. Materials and methods: A subanalysis of a prospective cohort collected between March 2014 and October 2016 was carried out at the San Vicente Fundación University Hospital (Medellin, Colombia), with trauma patients over 18 years of age. Lactate and clinical variables were measured at admission, at 6 and at 24hours. The association of lactate levels at admission and clearance with in hospital mortality was estimated, using logistic regression models. Results: A total of 251 patients met the inclusion criteria, 15.5% died, 45.4% required admission to intensive care, in patients who died the lactate at admission was 4.6mmol/L (Interquartile range = 2.9-6.9). The adjusted logistic regression model showed that lactate on admission, lactate clearance of 50% (0-24hours), trauma mechanism, and Sequential Organ Failure Assessment score were independent factors associated with mortality. Conclusion: High values of lactate at admission are associated with greater probability of dying and its clearance is an independent factor of mortality in those who enter with high lactate values.

Resumen Introducción: Valores elevados de lactato se relacionan con desenlaces adversos en casi todas las situaciones clínicas, los niveles de lactato por encima de 2mmol/L se proponen como marcador temprano y confiable de hipoperfusión tisular, igualmente se ha propuesto la depuración de lactato durante la reanimación como factor pronóstico. Objetivo: Determinar en pacientes traumatizados la asociación del valor inicial de lactato y su depuración después de 6 y 24 horas con mortalidad. Materiales y métodos: Se realizó un sub-análisis de una cohorte prospectiva recolectada entre marzo de 2.014 y octubre de 2.016 en el Hospital Universitario San Vicente Fundación (Medellín, Colombia), con pacientes mayores de 18 años poli traumatizados. Se midió el lactato y las variables clínicas al ingreso, a la hora 6 y a las 24. Se estimó la asociación con mortalidad hospitalaria, los niveles de lactato al ingreso y su depuración, mediante modelos de regresión logística. Resultados: 251 pacientes cumplieron criterios de inclusión, el 15.5% fallecieron, el 45.4% requirieron ingreso a cuidados intensivos, en pacientes que murieron el lactato al ingreso fue de 4,6 mmol/L (IQR=2,9-6,9), en el modelo de regresión logística ajustado se encontró que el lactato al ingreso, la depuración de lactato del 50% (0-24 horas), el mecanismo de trauma y el puntaje de SOFA fueron factores independientes asociados con mortalidad. Conclusión: Valores altos de lactato al ingreso se asocian con mayor probabilidad de morir y en quienes ingresan con valores de lactato elevados, su depuración es un factor independiente de mortalidad.

Asociación de variables clínicas de hipoperfusión con el lactato y la mortalidad / Association of clinical variables of hypoperfusion with lactate and mortality

Resumen Introducción: entre los pacientes con infección la hiperlactatemia identifica una población de mayor gravedad. Este estudio pretende determinar en pacientes de urgencias la correlación y asociación entre los parámetros clínicos de perfusión y los valores de lactato en el momento de admisión; así como el cambio en los parámetros clínicos con la depuración del lactato. Además, determinar la asociación entre estas variables y la mortalidad intrahospitalaria. Métodos: cohorte prospectiva de pacientes que ingresaron con sospecha de infección a un hospital de tercer nivel. Se midió el lactato en la admisión a las 6 y 24 horas, concomitantemente con las variables llenado capilar, índice de choque y presión de pulso, entre otras. Se realizó correlación de Spearman entre las variables clínicas, los niveles de lactato y su depuración; así como curvas ROC para determinar la capacidad discriminativa de las variables clínicas para detectar hiperlactatemia. Se realizó un modelo de regresión logística multivariable para mortalidad. Resultados: se evaluaron 2257 pacientes, 651 correspondían a infección confirmada. No se encontró ninguna correlación de utilidad entre las variables clínicas y el lactato (r<0.25); y tampoco se detectó adecuada capacidad discriminativa para la detección de hiperlactatemia con ninguna variable clínica (AUC<0.61). En el modelo de regresión logística multivariada el valor del lactato al ingreso fue la única variable que se asoció de manera independiente con mortalidad (OR=1.4, IC95%=1.3-1.6). Conclusiones: entre los pacientes que ingresan a urgencias con infección no se encontró correlación entre las variables clínicas y el lactato; sin embargo, el lactato al ingreso es un marcador pronóstico independiente de mortalidad. (Acta Med Colomb 2017: 42: 97-105).

Abstract Introduction: among patients with infection, hyperlactatemia identifies a population of greater severity. This study aims to determine the correlation and association between clinical perfusion parameters and lactate values in emergency patients at the time of admission, as well as the change in clinical parameters with lactate clearance. In addition, to determine the association between these variables and in-hospital mortality. Methods: Prospective cohort of patients admitted with suspected infection to a third level hospital. Lactate was measured at admission, at 6 and 24 hours, concomitantly with the variables capillary filling, shock index and pulse pressure, among others. Among the clinical variables, Spearman correlation, lactate levels and their clearance, as well as ROC curves to determine the discriminative ability of clinical variables to detect hyperlactatemia were performed. A multivariate logistic regression model for mortality was carried out. Results: 2257 patients were evaluated. 651 were confirmed with infections. No utility correlation was found between clinical variables and lactate (r <0.25), and no discriminative capacity was detected for the detection of hyperlactatemia with any clinical variable (AUC <0.61). In the multivariate logistic regression model the lactate value at admission was the only variable that was independently associated with mortality (OR = 1.4, 95% CI = 1.3-1.6). Conclusions: no correlation was found between clinical variables and lactate among patients admitted to the emergency department with infection; however lactate at admission is an independent prognostic marker of mortality. (Acta Med Colomb 2017: 42: 97-105).

Desarrollo y validación de un modelo predictor para bacteriemia en pacientes hospitalizados por el servicio de urgencias con sospecha de infección / Development and validation of a predictive model for bacteremia in patients hospitalized by the emergency department with suspected infection

Background: Positive blood cultures usually indicate disseminated infection that is associated with a poor prognosis and higher mortality. We seek to develop and validate a predictive model to identify factors associated with positive blood cultures in emergency patients. Methods: Secondary analysis of data from two prospective cohorts (EPISEPSIS: developing cohort, and DISEPSIS: validation cohort) of patients with suspected or confirmed infection, assembled in emergency services in 10 hospitals in four cities in Colombia between September 2007 and February 2008. A logistic multivariable model was fitted to identify clinical and laboratory variables predictive of positive blood culture. Results: We analyzed 719 patients in developing and 467 in validation cohort with 32% and 21% positive blood cultures, respectively. The final predictive model included variables with significant coefficients for both cohorts: temperature > 38° C, Glasgow < 15 and platelet < 150.000 cells/mm³, with calibration (goodness-of-fit H-L) p = 0.0907 and p = 0.7003 and discrimination AUC = 0.68 (95% CI = 0.65-0.72) and 0.65 (95% CI = 0.61-0.70) in EPISEPSIS and DISEPSIS, respectively. Specifically, temperature > 38 °C and platelets < 150.000 cells/mm³ and normal Glasgow; or Glasgow < 15 with normal temperature and platelets exhibit a LR between 1,9 (CI 95% = 1,2-3,1) and 2,3 (CI 95% = 1,7-3,1). Glasgow < 15 with any of low platelets or high temperature shows a LR between 2,2 (CI 95% = 1,1-4,4) and 2,6 (CI 95% = 1,7-4,3). Discussion: Temperature > 38° C, platelet count < 150,000 cells/mm³ and GCS < 15 are variables associated with increased likelihood of having a positive blood culture.

Introducción: Un hemocultivo positivo usualmente indica infección diseminada, la que se asocia con peor pronóstico y mayor mortalidad. Por tanto, buscamos desarrollar y validar un modelo de predicción que permita identificar los factores asociados con la positividad de los hemocultivos en pacientes del servicio de urgencias. Métodos: Análisis secundario de datos de dos cohortes prospectivas (EPISEPSIS: cohorte de desarrollo y DISEPSIS: cohorte de validación) de pacientes con sospecha o confirmación de infección, ensambladas en servicios de urgencias de 10 instituciones hospitalarias en cuatro ciudades de Colombia entre septiembre de 2007 y febrero de 2008. Se ajustó un modelo logístico multivariado para identificar variables clínicas y de laboratorio predictoras de hemocultivos positivos. Resultados: Se analizaron 719 pacientes en la cohorte de desarrollo y 467 en la cohorte de validación, con 32 y 21% de hemocultivos positivos, respectivamente. El modelo predictor final incluyó las variables con coeficientes significativos para ambas cohortes: temperatura ≥ 38 °C, Glasgow < 15 y plaquetas ≤ 150.000 céls/mm³ con calibración (bondad de ajuste de H-L) p = 0,0907 y p = 0,7003 y discriminación AUC: 0,68 (IC 95%: 0,65-0,72) y 0,65 (IC 95%: 0,61-0,70) en EPISEPSIS y DISEPSIS, respectivamente. Temperatura ≥ 38 °C y recuento de plaquetas ≤ 150.000 céls/mm³ con Glasgow normal; o Glasgow < 15 con temperatura y plaquetas normales tiene un LR entre 1,9 (IC 95%: 1,2-3,1) y 2,3 (IC 95%: 1,7-3,1). La escala de Glasgow < 15 puntos junto con cualquiera entre recuento de plaquetas o temperatura alteradas tiene un LR entre 2,2 (IC 95%: 1,1-4,4) y 2,6 (IC 95%: 1,7-4,3). Discusión: La temperatura ≥ 38 °C, el recuento de plaquetas ≤ 150.000 céls/mm³ y la escala de Glasgow < 15 son las variables asociadas con mayor probabilidad de tener un hemocultivo positivo.