Persistent high sepsis-induced coagulopathy and sequential organ failure assessment scores can predict the 28-day mortality of patients with sepsis: A prospective study.

BACKGROUND: The performance of the sepsis-induced coagulopathy (SIC) and sequential organ failure assessment (SOFA) scores in predicting the prognoses of patients with sepsis has been validated. This study aimed to investigate the time course of SIC and SOFA scores and their association with outcomes in patients with sepsis. METHODS: This prospective study enrolled 209 patients with sepsis admitted to the emergency department. The SIC and SOFA scores of the patients were assessed on days 1, 2, and 4. Patients were categorized into survivor or non-survivor groups based on their 28-day survival. We conducted a generalized estimating equation analysis to evaluate the time course of SIC and SOFA scores and the corresponding differences between the two groups. The predictive value of SIC and SOFA scores at different time points for sepsis prognosis was evaluated. RESULTS: In the non-survivor group, SIC and SOFA scores gradually increased during the first 4 days (P < 0.05). In the survivor group, the SIC and SOFA scores on day 2 were significantly higher than those on day 1 (P < 0.05); however, they decreased on day 4, dropping below the levels observed on day 1 (P < 0.05). The non-survivors showed higher SIC scores on days 2 (P < 0.05) and 4 (P < 0.001) than the survivors, whereas no significant differences were found between the two groups on day 1 (P > 0.05). The performance of SIC scores on day 4 for predicting mortality was more accurate than that on day 2, with areas under the curve of 0.749 (95% confidence interval [CI]: 0.674-0.823), and 0.601 (95% CI: 0.524-0.679), respectively. The SIC scores demonstrated comparable predictive accuracy for 28-day mortality to the SOFA scores on days 2 and 4. Cox proportional hazards models indicated that SIC on day 4 (hazard ratio [HR] = 3.736; 95% CI: 2.025-6.891) was an independent risk factor for 28-day mortality. CONCLUSIONS: The time course of SIC and SOFA scores differed between surviving and non-surviving patients with sepsis, and persistent high SIC and SOFA scores can predict 28-day mortality.

Establishment and validation of a prognosis nomogram for MIMIC-III patients with liver cirrhosis complicated with hepatic encephalopathy.

INTRODUCE: The purpose of this study was to establish a comprehensive prognosis nomogram for patients with liver cirrhosis complicated with hepatic encephalopathy (HE) in the intensive care unit (ICU) and to evaluate the predictive value of the nomogram. METHOD: This study analyzed 620 patients with liver cirrhosis complicated with HE from the Medical Information Mart for Intensive Care III(MIMIC-III) database. The patients were randomly divided into two groups in a 7-to-3 ratio to form a training cohort (n = 434) and a validation cohort (n = 176). Cox regression analyses were used to identify associated risk variables. Based on the multivariate Cox regression model results, a nomogram was established using associated risk predictor variables to predict the 90-day survival rate of patients with cirrhosis complicated with HE. The new model was compared with the Sequential organ failure assessment (SOFA) scoring model in terms of the concordance index (C-index), the area under the curve (AUC) of receiver operating characteristic (ROC) analysis, the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), calibration curve, and decision curve analysis (DCA). RESULTS: This study showed that older age, higher mean heart rate, lower mean arterial pressure, lower mean temperature, higher SOFA score, higher RDW, and the use of albumin were risk factors for the prognosis of patients with liver cirrhosis complicated with HE. The use of proton pump inhibitors (PPI) was a protective factor. The performance of the nomogram was evaluated using the C-index, AUC, IDI value, NRI value, and DCA curve, showing that the nomogram was superior to that of the SOFA model alone. Calibration curve results showed that the nomogram had excellent calibration capability. The decision curve analysis confirmed the good clinical application ability of the nomogram. CONCLUSION: This study is the first study of the 90-day survival rate prediction of cirrhotic patients with HE in ICU through the data of the MIMIC-III database. It is confirmed that the eight-factor nomogram has good efficiency in predicting the 90-day survival rate of patients.

Therapeutic plasma exchange in patients with sepsis: Secondary analysis of a cluster-randomized controlled trial.

INTRODUCTION: Sepsis is life-threatening organ dysfunction caused by infection-related inflammatory response. Therapeutic plasma exchange (TPE) can remove inflammatory mediators and benefit patients in different disease settings. However, no solid evidence showed the efficacy and safety of TPE in sepsis. METHODS: This study was a secondary analysis of a randomized controlled trial. Critically ill patients with sepsis were divided into two groups according to whether treated with TPE. The primary outcome was the delta Sequential Organ Failure Assessment (SOFA) score from days 1 to 7. Secondary outcomes included new-onset organ failure, intensive care unit (ICU)-free and alive days to day 28, and 28-day mortality. Propensity score-matched (PSM) analysis was applied to control confounders. Analysis of covariance (ANCOVA) and logistic regression were used to assess the association between TPE and selected outcomes. RESULTS: Among the 2772 critically ill patients enrolled in the trial, 742 patients with sepsis were selected and 22 patients received TPE were matched with 22 control patients. No significant difference was found in the delta SOFA score and 28-day mortality between TPE group and control group. The ICU-free and alive days in the TPE group were significantly shorter than the control group. CONCLUSIONS: TPE may be not associated with improvement of organ failure and mortality in critically ill patients with sepsis and may be associated with a prolonged ICU stay.

Epidemiology of sepsis in Internal Medicine Units of Apulia: results of SEMINA (SEpsis Management in INternal medicine Apulia) study.

Background: The prevalence and mortality of sepsis in Internal Medicine Units (IMUs) is poorly understood as most of the data derive from studies conducted in Intensive Care Units. Aim of SEpsis Management in INternal medicine Apulia (SEMINA) study was to determine the prevalence of sepsis and the characteristics and outcomes of patients with Sepsis-3 criteria admitted in Apulia's Internal Medicine Units for over six months. Methods: The SEpsis Management in INternal medicine of Apulia study was a prospective, multicentre, observational study. Adult admissions to the 13 Apulia Region's Internal Medicine Units between November 15, 2018 and May 15, 2019 were screened for sepsis according to the Sepsis-3 criteria. Medical data were collected in electronic case report form. Results: Out of 7,885 adult patients of the Internal Medicine Units, 359 (4.55%) fulfilled the inclusion criteria, and 65 of them (18.1%) met the septic shock criteria. The patients enrolled were elderly, suffering from chronic poly-pathologies and from cognitive and functional impairment. The respiratory system was the most common site of infection and the most common pathogens isolated from blood cultures were Staphylococcus spp., E. coli, Klebsiella spp., Enterococcus spp. and Acinetobacter spp. The in-hospital fatality rate was 31.2% and was significantly higher for septic shock. Sequential Organ Failure Assessment score, dementia and infections from Acinetobacter spp. were independent risk factors for mortality. Conclusions: A high prevalence of sepsis and a high fatality rate were detected in Apulia Region's Internal Medicine Units. The high fatality rate observed in our study could be related to the underlying diseases and to the vulnerability of elderly patients admitted to our Internal Medicine Units.

SOFA-based Prognostication in PICU: A Cardiovascular Critique!

How to cite this article: Magoon R. SOFA-based Prognostication in PICU: A Cardiovascular Critique! Indian J Crit Care Med 2023;27(11):861-862.

Serial Evaluation of Sequential Organ Failure Assessment Score (SOFA) as a Predictor of Outcome in Children Admitted in Pediatric Intensive Care Unit (PICU) at Tertiary Care Hospital.

Background: Sequential organ failure assessment score (SOFA) is a score to quantify organ system dysfunction. This study was done to evaluate SOFA as a predictor of outcomes in children in pediatric intensive care unit (PICU). Objective: (A) To determine whether initial SOFA, Delta SOFA, and SOFA score at 72 hours are better predictors of outcome in terms of sensitivity and specificity. (B) To compare the initial SOFA, Delta SOFA, and SOFA score at 72 hours. Materials and methods: A prospective observational study was conducted on 160 patients aged from 29 days to 12 years admitted in PICU of a Tertiary Care Hospital in a metropolitan city in India for a period of 1 year. Then, the initial SOFA score, 72-hour SOFA, and Delta SOFA (T0 SOFA - T72 SOFA) were calculated and patients were followed up till discharge from PICU or deceased. Results: The best threshold to differentiate between discharged and deceased corresponds to as initial SOFA of 7.50 with a sensitivity of 64.71%, and specificity of 89.51%. The similar threshold for 72 hours SOFA is 10.50 which correspond to a sensitivity of 76.47% and specificity of 96.50%. The study showed strong evidence (p-value < 0.05) that, patients whose Delta SOFA values increased from the previous value (-1.5), had a greater chance to succumb to illness. Delta SOFA had the best sensitivity (82.35%) and 72-hour SOFA had the best specificity (96.50%) in predicting the outcome of PICU patients. Conclusion: This study emphasizes the use of SOFA score as a prognostic indicator in critically ill children, as variables measured are easily available. How to cite this article: Lois A, Save S. Serial Evaluation of Sequential Organ Failure Assessment Score (SOFA) as a Predictor of Outcome in Children Admitted in Pediatric Intensive Care Unit (PICU) at Tertiary Care Hospital. Indian J Crit Care Med 2023;27(8):590-595.

Author Reply - SOFA-based Prognostication in PICU: A Cardiovascular Critique!

How to cite this article: Lois A, Save S. Author Reply - SOFA-based Prognostication in PICU: A Cardiovascular Critique! Indian J Crit Care Med 2023;27(11):863.

Trends in mortality in septic patients according to the different organ failure during 15 years.

BACKGROUND: The incidence of sepsis can be estimated between 250 and 500 cases/100.000 people per year and is responsible for up to 6% of total hospital admissions. Identified as one of the most relevant global health problems, sepsis is the condition that generates the highest costs in the healthcare system. Important changes in the management of septic patients have been included in recent years; however, there is no information about how changes in the management of sepsis-associated organ failure have contributed to reduce mortality. METHODS: A retrospective analysis was conducted from hospital discharge records from the Minimum Basic Data Set Acute-Care Hospitals (CMBD-HA in Catalan language) for the Catalan Health System (CatSalut). CMBD-HA is a mandatory population-based register of admissions to all public and private acute-care hospitals in Catalonia. Sepsis was defined by the presence of infection and at least one organ dysfunction. Patients hospitalized with sepsis were detected, according ICD-9-CM (since 2005 to 2017) and ICD-10-CM (2018 and 2019) codes used to identify acute organ dysfunction and infectious processes. RESULTS: Of 11.916.974 discharges from all acute-care hospitals during the study period (2005-2019), 296.554 had sepsis (2.49%). The mean annual sepsis incidence in the population was 264.1 per 100.000 inhabitants/year, and it increased every year, going from 144.5 in 2005 to 410.1 in 2019. Multiorgan failure was present in 21.9% and bacteremia in 26.3% of cases. Renal was the most frequent organ failure (56.8%), followed by cardiovascular (24.2%). Hospital mortality during the study period was 19.5%, but decreases continuously from 25.7% in 2005 to 17.9% in 2019 (p < 0.0001). The most important reduction in mortality was observed in cases with cardiovascular failure (from 47.3% in 2005 to 31.2% in 2019) (p < 0.0001). In the same way, mean mortality related to renal and respiratory failure in sepsis was decreased in last years (p < 0.0001). CONCLUSIONS: The incidence of sepsis has been increasing in recent years in our country. However, hospital mortality has been significantly reduced. In septic patients, all organ failures except liver have shown a statistically significant reduction on associated mortality, with cardiovascular failure as the most relevant.

Gut Dysbiosis Associated with Antibiotics and Disease Severity and Its Relation to Mortality in Critically Ill Patients.

BACKGROUND: The gut microbiota are reported to be altered in critical illness. The pattern and impact of dysbiosis on prognosis has not been thoroughly investigated in the ICU setting. AIMS: We aimed to evaluate changes in the gut microbiota of ICU patients via 16S rRNA gene deep sequencing, assess the association of the changes with antibiotics use or disease severity, and explore the association of gut microbiota changes with ICU patient prognosis. METHODS: Seventy-one mechanically ventilated patients were included. Fecal samples were collected serially on days 1-2, 3-4, 5-7, 8-14, and thereafter when suitable. Microorganisms of the fecal samples were profiled by 16S rRNA gene deep sequencing. RESULTS: Proportions of the five major phyla in the feces were diverse in each patient at admission. Those of Bacteroidetes and Firmicutes especially converged and stabilized within the first week from admission with a reduction in α-diversity (p < 0.001). Significant differences occurred in the proportional change of Actinobacteria between the carbapenem and non-carbapenem groups (p = 0.030) and that of Actinobacteria according to initial SOFA score and changes in the SOFA score (p < 0.001). An imbalance in the ratio of Bacteroidetes to Firmicutes within seven days from admission was associated with higher mortality when the ratio was > 8 or < 1/8 (odds ratio: 5.54, 95% CI: 1.39-22.18, p = 0.015). CONCLUSIONS: Broad-spectrum antibiotics and disease severity may be associated with gut dysbiosis in the ICU. A progression of dysbiosis occurring in the gut of ICU patients might be associated with mortality.

Early high-dose continuous veno-venous hemofiltration alleviates the alterations of CD4+ T lymphocyte subsets in septic patients combined with acute kidney injury.

BACKGROUND: This study aims to determine whether early high-dose continuous venous-venous hemofiltration (CVVH) alleviates the alterations in CD4+ T lymphocyte subsets in septic patients combined with acute kidney injury. METHODS: Enrolled septic patients combined with acute kidney injury were randomized into CVVH (n = 50) and conventional treatment (non-CVVH, n = 53) groups. Healthy volunteers (n = 21) were enrolled. CVVH was initiated within 12 h of intensive care unit (ICU) admission with doses of 35~60 ml/kg/h and maintained for at least 72 h. Th1, Th2, Th17, and Treg were measured by flow cytometry on days 1, 3, and 7 of ICU admission. Sequential organ failure assessment (SOFA) scores were calculated. RESULTS: Th1 percentages and Th1/Th2 ratios were lower, and Th2, Th17, and Treg percentages and Th17/Treg ratios were higher in septic patients compared to healthy volunteers. CVVH significantly increased Th1 percentages and Th1/Th2 ratios, and significantly decreased Th2, Th17, and Treg percentages and Th17/Treg ratios compared to non-CVVH. Th1 percentages and Th1/Th2 ratios were negatively correlated with SOFA scores, while Th2, Th17, and Treg percentages and Th17/Treg ratios were positively correlated with SOFA scores. Patients with CVVH had significantly lower SOFA scores on day 7 of ICU admission and a shorter ICU stay compared to those with non-CVVH. CONCLUSIONS: Septic patients combined with acute kidney injury exhibit different alterations of CD4+ T lymphocyte subsets. Early high-dose CVVH alleviates the alterations, which may be one of the factors associated with improved sepsis severity.

Sepsis in Intensive Care Unit: Which Score Predicts Better about Outcome?

How to cite this article: Clerk AM. Sepsis in Intensive Care Unit: Which Score Predicts Better about Outcome? Indian J Crit Care Med 2022;26(10):1072-1073.

Mortality related to drug-resistant organisms in surgical sepsis-3: an 8-year time trend study using sequential organ failure assessment scores.

The difference in sequential organ failure assessment (SOFA) scores from the baseline to sepsis is a known predictor of sepsis-3 outcome, but the prognostic value of drug-resistant organisms for mortality is unexplained. We employed sepsis stewardship and herein report an observational study. Study subjects were patients admitted to the Departments of Surgery/Chest Surgery from 2011 through 2018 with a diagnosis of sepsis and a SOFA score of 2 or more. Our sepsis stewardship methods included antimicrobial and diagnostic stewardship and infection control. We determined the primary endpoint as in-hospital death and the secondary endpoint as the annual trend of the risk-adjusted mortality ratio (RAMR). For mortality, we performed logistic regression analysis based on SOFA score, age, sex, comorbid disease, and the presence of methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase inhibitor-producing bacteria. In a total of 457 patients, two factors were significant predictors for fatality, i.e., SOFA score of 9 or more with an odds ratio (OR) 4.921 and 95% confidence interval [95% CI] 1.968-12.302 (P = 0.001) and presence of MRSA with an OR 1.83 and 95% CI 1.003-3.338 (P = 0.049). RAMR showed a decrease during the study years (P < 0.05). Early detection of MRSA may help patients survive surgical sepsis-3. Thus, MRSA-oriented diagnosis may play a role in expediting treatment with anti-MRSA antimicrobials.

Epidemiology, Clinical Characteristics, and Prognostic Factors in Critically Ill Patients with Hematolymphoid Malignancy.

OBJECTIVE: Despite advances in the field of oncology and intensive care, the outcomes of hematolymphoid malignancy (HLM) patients admitted to ICU are poor. This study was carried out to look at the demographic data, clinical features, and predictors of hospital mortality in these patients. MATERIALS AND METHODS: We prospectively studied 101 adult critically ill patients with HLM admitted to the 14-bedded mixed medical surgical ICU of a tertiary care cancer center. Out of 101 patients, end-of-life care decisions were taken in 7 patients, who were excluded from the outcome analysis. Predictors of in-hospital mortality were evaluated using univariate and multivariate analysis. RESULTS: The ICU and in-hospital mortality recorded in our study were 48.9 and 54.3%, respectively. Neutropenia at ICU admission, Simplified Acute Physiology Score III (SAPS III) score, and mechanical ventilation (MV) within 24 hours of ICU admission were associated with in-hospital mortality on univariate analysis. On multivariate logistic regression analysis, neutropenia at ICU admission (OR 4.621; 95% CI, 1.2-17.357) and MV within 24 hours of ICU admission (OR 2.728; 95% CI, 1.077-6.912) were independent predictors of in-hospital mortality. CONCLUSION: The HLM patients needing critical care have high acuity of illness, and acute respiratory failure is the commonest reason for ICU admission in these patients. In our study, the ICU survival was more than 50% and more than 45% patients were discharged alive from the hospital. We found a need for MV within 24 hours of ICU admission and presence of neutropenia at ICU admission to be independent predictors of hospital mortality in our study. HOW TO CITE THIS ARTICLE: Siddiqui SS, Prabu NR, Chaudhari HK, Narkhede AM, Sarode SV, Dhundi U, et al. Epidemiology, Clinical Characteristics, and Prognostic Factors in Critically Ill Patients with Hematolymphoid Malignancy. Indian J Crit Care Med 2021;25(1):56-61.

Risk factors of in-hospital mortality in adult postcardiotomy cardiogenic shock patients successfully weaned from venoarterial extracorporeal membrane oxygenation.

OBJECTIVE: Mortality of adult postcardiotomy cardiogenic shock patients after successfully weaned from venoarterial extracorporeal membrane oxygenation remains high. The objective of this study is to identify the risk factors associated with mortality after successfully weaning from venoarterial extracorporeal membrane oxygenation in adult postcardiotomy cardiogenic shock patients. METHODS: All consecutive patients who were successfully weaned from venoarterial extracorporeal membrane oxygenation between January 2011 and December 2016 at the Beijing Anzhen Hospital were analyzed retrospectively. Multivariate logistic regression was performed to identify risk factors associated with in-hospital mortality after successfully weaning from venoarterial extracorporeal membrane oxygenation. RESULTS: In total, 212 (58.4%) of 363 postcardiotomy cardiogenic shock patients were successfully weaned from venoarterial extracorporeal membrane oxygenation. The non-survivors had a longer duration of extracorporeal membrane oxygenation than the survivors (120.0 (98.0, 160.50) vs. 100.0 (77.0, 126.0), p = 0.000). Variables associated with mortality of patients successfully weaned from extracorporeal membrane oxygenation by univariable analysis were age, diabetes, vasoactive inotropic score pre-extracorporeal membrane oxygenation, vasoactive inotropic score at weaning, left ventricular ejection fraction at weaning, central venous pressure at weaning, sequential organ failure assessment score pre-extracorporeal membrane oxygenation, sequential organ failure assessment at weaning, survival after venoarterial ECMO pre-extracorporeal membrane oxygenation, and survival after venoarterial ECMO at weaning. In the multivariate analysis, sequential organ failure assessment score at weaning (odds ratio = 1.889, 95% confidence interval = 1.460-2.455, p < 0.001) was an independent risk factor for in-hospital mortality of patients successfully weaned from venoarterial extracorporeal membrane oxygenation. The cumulative 30-day survival rate in patients with a sequential organ failure assessment score < 7 was significantly (p < 0.001) higher than in patients with a sequential organ failure assessment score ⩾ 7 (87% vs. 56.7%, p < 0.001). CONCLUSION: Vasoactive inotropic score, left ventricular ejection fraction, central venous pressure, and sequential organ failure assessment score at weaning were associated with in-hospital mortality for postcardiotomy cardiogenic shock patients successfully weaned from venoarterial extracorporeal membrane oxygenation. Sequential organ failure assessment score might help clinicians to predict in-hospital mortality for patients successfully weaned from venoarterial extracorporeal membrane oxygenation.

Obstetric Early Warning Score for Prognostication of Critically Ill Obstetric Patient.

INTRODUCTION: Obstetric early warning score (OEWS) has been used conventionally for early identification of deteriorating obstetric patients in the labor room and ward settings. This study was conducted to determine if this simple clinical score could be used for prognosticating a critically ill patient in the ICU setting instead of sequential organ failure assessment score (SOFA) and acute physiology and chronic health evaluation (APACHE II) score. MATERIALS AND METHODS: A cohort study was conducted at Obstetrics Critical Care Unit, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi. A total of 250 obstetric patients were recruited after informed consent. The OEWS, SOFA, and APACHE II scores were calculated within 24 hours of admission. The patients were followed to study the maternal outcome. RESULTS: The area under receiver operator characteristic (AUROC) curve of OEWS, SOFA, and APACHE II for prediction of maternal mortality was 0.894 (95% CI, 0.849-0.929), 0.924 (95% CI, 0.884-0.954), and 0.93 (95% CI, 0.891-0.958), respectively. The standardized mortality ratio (SMR) for OEWS, SOFA, and APACHE II was 66.3, 62.5, and 69.15%, respectively. CONCLUSION: Obstetric early warning score is as effective as the conventional SOFA and APACHE II to prognosticate the obstetric patient. Since OEWS is based only on clinical criteria, it can be done immediately on admission and can help in early allocation of appropriate manpower and resources for optimum outcome. CLINICAL SIGNIFICANCE: The clinical application of this study will help intensivists to prognosticate the critically ill obstetric patients immediately following admission to the critical care unit. HOW TO CITE THIS ARTICLE: Khergade M, Suri J, Bharti R, Pandey D, Bachani S, Mittal P. Obstetric Early Warning Score for Prognostication of Critically Ill Obstetric Patient. Indian J Crit Care Med 2020;24(6):398-403.

The SOFA score could predict the severity and prognosis of infective endocarditis.

INTRODUCTION: Although infectious endocarditis (IE) is a potentially severe infectious disease, there are no prognostic tools for in-hospital mortality for IE patients. This is the first report documenting that the Sequential Organ Failure Assessment (SOFA) score could evaluate the severity and outcome among IE patients. PATIENTS AND METHODS: From 2007 to 2018, we reviewed all patients who were diagnosed as having IE at our institue. Patients diagnosed as definite IE according to the modified Duke criteria or by surgical procedure were included in this study. RESULTS: A total of 66 IE patients were enrolled in this study. They were 45 males (68%) and the median age was 70 years. As for prognostic factors for in-hospital death among IE patients, SOFA score ≥6, CCI ≥3, surgical procedure, heart failure, immunological phenomena and detection of S. aureus as a causative pathogen were identified as prognostic factors by univariate analysis. Of these 6 factors, SOFA score ≥6 (OR 7.6, 95%CI 1.3-46.6, p = 0.029), heart failure (OR 9.7, 95%CI 1.1-86.1, p = 0.042), surgery (OR 0.1, 95%CI 0-0.8, p = 0.037) and immunological phenomena (OR 0.1, 95%CI 0-0.9, p = 0.042) were independent prognostic factors for in-hospital mortality among IE by logistic regression analysis. CONCLUSION: The SOFA score could be a good prognostic tool to use for IE patients. Also, SOFA score ≥6, surgery, immunological phenomena and heart failure were independent prognostic factors for in-hospital mortality among IE patients.

Mortality and risk factor analysis for Candida blood stream infection: A multicenter study.

Candida blood stream infection (candidemia) is severe systemic infection mainly develops after intensive medical cares. The mortality of candidemia is affected by the underlying conditions, causative agents and the initial management. We retrospectively analyzed mortality-related risk factors in cases of candidemia between April 2011 and March 2016 in five regional hospitals in Japan. We conducted bivariate and multivariate analysis of factors including causative Candida species, patients' predisposing conditions, and treatment strategies, such as empirically selected antifungal drug and time to appropriate antifungal treatment, to elucidate their effects on 30-day mortality. The study enrolled 289 cases of candidemia in adults. Overall 30-day mortality was 27.7%. Forty-nine cases (17.0%) were community-acquired. Bivariate analysis found advanced age, high Sequential Organ Failure Assessment (SOFA) score, and prior antibiotics use as risk factors for high mortality; however community-acquired candidemia, C. parapsilosis candidemia, obtaining follow-up blood culture, and empiric treatment with fluconazole were associated with low mortality. Logistic regression revealed age ≥65 years (adjusted odds ratio, 2.13) and sequential organ failure assessment (SOFA) score ≥6 (6.30) as risk factors for 30-day mortality. In contrast, obtaining follow-up blood culture (0.38) and empiric treatment with fluconazole (0.32) were found to be protective factors. The cases with candidemia in associated with advanced age and poor general health conditions should be closely monitored. Obtaining follow-up blood culture contributed to an improved prognosis.

Prehospital quick sequential organ failure assessment score to predict in-hospital mortality among patients with trauma.

OBJECTIVE: The quick sequential organ failure assessment (qSOFA) score is calculated from three variables measured at the scene of trauma-systolic blood pressure, respiratory rate and consciousness. This study aimed to evaluate the discriminative ability of the prehospital qSOFA score for in-hospital mortality in patients with trauma. METHODS: This retrospective multicenter study used data from 42,722 patients with trauma included in a Japanese nationwide trauma registry. All included patients were aged ≥18 years old and transferred to hospitals from the scenes of injury. The primary outcome was in-hospital mortality. RESULTS: The included patients had a mean age of 59.4 ±â€¯21.5 years and a male predominance (63%). In-hospital mortality occurred in 2612 patients (6%), while 2-day mortality occurred in 1189 of 42,339 patients (3%). When patients were stratified by qSOFA scores, in-hospital mortality rates of 0.9% (105/11783), 5% (941/17839), 12% (1280/11132) and 15% (286/1968) were associated with qSOFA scores of 0, 1, 2 and 3, respectively (P < 0.0001 for trend). The area under the receiver operating characteristics curve of the qSOFA score for in-hospital mortality was 0.70 (95% confidence interval: 0.69-0.71). A qSOFA score cutoff value ≥1 yielded a sensitivity and specificity of 0.96 and 0.29, respectively, overall, and a sensitivity of 0.99 in patients younger than 65 years. CONCLUSIONS: The prehospital qSOFA score was strongly associated with in-hospital mortality in patients with trauma. A prehospital qSOFA score cutoff of ≥1 can be used to identify patients at a very low risk of death, especially in younger age groups.

Role of C-reactive Protein as an Indicator for Determining the Outcome of Sepsis.

BACKGROUND AND AIMS: It has been observed that after any injury which is acute and also in the setting of inflammation or infection, the synthesis and secretion of C-reactive protein (CRP) rises within a few hours. The current study monitors CRP in patients presenting with sepsis and attempts to prove that it is one of the most reliable tests in determining the resolution and predicting the outcome. MATERIALS AND METHODS: During 12 months, 97 individuals with culture-proven sepsis were included, and a prospective observational study was done. Patients were assessed clinically by recording vitals, mean arterial pressure, Glasgow coma scale score, sequential organ failure assessment (SOFA) score as well as assessment of arterial blood gas and other blood investigations, which included CRP, total white cell count, differential count, serum creatinine, serum bilirubin on day 0, day 2 and day 5 after initiating antibiotics. To test the statistical significance of the difference in mean percentage changes of the different study variables between living and expired groups at day 2 and day 5, Wilcoxon's rank sum test was applied due to the non-normal distribution of values and small sample sizes. RESULTS: The percentage drop of the mean of CRP from day 0 to day 2 was 23.33% in the living group, and there was an increase of 4.73 % in the expired group. The percentage drop of the mean of CRP on day 5 when compared to day 0, was significant in the living group. CONCLUSION: C-reactive protein (CRP) is a more useful tool in predicting improvement and outcome in patients admitted with sepsis when compared to scoring systems like SOFA score. ABBREVIATIONS: AIMS: Amrita Institute of Medical Sciences, C1q: Complement 1q, CRP: C-reactive Protein, PCT: Procalcitonin, SOFA: Sequential organ failure assessment. HOW TO CITE THIS ARTICLE: Anush MM, Ashok VK, Sarma RIN, Pillai SK. Role of C-reactive Protein as an Indicator for Determining the Outcome of Sepsis. Indian Journal of Critical Care Medicine, January 2019; 23(1):11-14.

Clinical characteristics, organ failure, inflammatory markers and prediction of mortality in patients with community acquired bloodstream infection.

BACKGROUND: Community acquired bloodstream infection (CABSI) in low- and middle income countries is associated with a high mortality. This study describes the clinical manifestations, laboratory findings and correlation of SOFA and qSOFA with mortality in patients with CABSI in northern Vietnam. METHODS: This was a retrospective study of 393 patients with at least one positive blood culture with not more than one bacterium taken within 48 h of hospitalisation. Clinical characteristic and laboratory results from the first 24 h in hospital were collected. SOFA and qSOFA scores were calculated and their validity in this setting was evaluated. RESULTS: Among 393 patients with bacterial CABSI, approximately 80% (307/393) of patients had dysfunction of one or more organ on admission to the study hospital with the most common being that of coagulation (57.1% or 226/393). SOFA performed well in prediction of mortality in those patients initially admitted to the critical care unit (AUC 0.858, 95%CI 0.793-0.922) but poor in those admitted to medical wards (AUC 0.667, 95%CI 0.577-0.758). In contrast qSOFA had poor predictive validity in both settings (AUC 0.692, 95%CI 0.605-0.780 and AUC 0.527, 95%CI 0.424-0.630, respectively). The overall case fatality rate was 28%. HIV infection (HR = 3.145, p = 0.001), neutropenia (HR = 2.442, p = 0.002), SOFA score 1-point increment (HR = 1.19, p < 0.001) and infection with Enterobacteriaceae (HR = 1.722, p = 0.037) were independent risk factors for in-hospital mortality. CONCLUSIONS: Organ dysfunction was common among Vietnamese patients with CABSI and associated with high case fatality. SOFA and qSOFA both need to be further validated in this setting.