Performance of Six Clinical Physiological Scoring Systems in Predicting In-Hospital Mortality in Elderly and Very Elderly Patients with Acute Upper Gastrointestinal Bleeding in Emergency Department.

Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated and compared with in-hospital mortality. Results: A total of 336 patients were recruited, of whom 40 died. There is a significant difference between the patients in the mortality group and survival group in terms of the six scoring systems. MEWS had the highest area under the curve (AUC) value (0.82). A subgroup analysis was performed for a total of 180 very elderly patients (i.e., older than 75 years), of whom 27 died. MEWS also had the best predictive performance in this subgroup (AUC, 0.82). Conclusions: This simple, rapid, and obtainable-by-the-bed parameter could assist emergency physicians in risk stratification and decision making for this vulnerable group.

Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-analysis.

BACKGROUND: The 2010 Advanced Cardiac Life Support guidelines stated that routine sodium bicarbonate (SB) use for cardiac arrest patients was not recommended. However, SB administration during resuscitation is still common. OBJECTIVES: To evaluate the effect of SB on return of spontaneous circulation (ROSC) and survival-to-discharge rates in adult cardiac arrest patients. METHODS: We searched Medline, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to December 2019. We included trials on nontraumatic adult patients after cardiac resuscitation and SB treatment vs. controls. RESULTS: A meta-analysis was performed with six observational studies, including 18,406 adult cardiac arrest patients. There were no significant differences in the ROSC rate (odds ratio [OR] 1.185; 95% confidence interval [CI] 0.680-2.065) and survival-to-discharge rate (OR 0.296; 95% CI 0.066-1.323) between the SB and no-SB groups. In the subgroup analysis based on the year factor, there were no significant differences in the mortality rate in the After-2010 group. In the subgroup analysis based on the continent, the ROSC rate (OR 0.521; 95% CI 0.432-0.628) and survival-to-discharge rate (OR 0.102; 95% CI 0.066-0.156) were significantly lower in the North American group. CONCLUSIONS: SB use was not associated with improvement in ROSC or survival-to-discharge rates in cardiac resuscitation. In addition, mortality was significantly increased in the North American group with SB administration.

Identifying necrotizing soft tissue infection using infectious fluid analysis and clinical parameters based on machine learning algorithms.

Background: Determining the presence of necrotizing soft tissue infection (NSTI) poses a significant hurdle. As of late, there has been a notable increase in the application of artificial intelligence (AI) machine learning techniques in identifying diseases, a shift that can be attributed to their exceptional efficiency, unbiased nature, and high precision. Methods: Information was gathered from a cohort of 13 patients suffering from NSTI, alongside 12 patients with cellulitis. The construction of NSTI diagnostic machine learning models utilized four different algorithms, specifically random forest, k-nearest neighbors (KNN), support vector machine (SVM), and logistic regression. These models were constructed based on 28 distinctive attributes identified through statistical examination. Following this, the diagnostic efficiency of each algorithms was evaluated. A novel random forest model, streamlined for clinical use, was later developed by focusing on 6 attributes that had the most pronounced influence on the accuracy of our initial random forest model. Results: The following data was noted regarding the sensitivity and specificity of the four NSTI diagnostic models:logistic regression displayed 78.2 % and 83.7 %, KNN presented 79.1 % and 87.1 %, SVM showed 83.5 % and 86.3 %, and random forest exhibited 89.6 % and 92.9 %, respectively. In comparison, lactate levels in fluid demonstrated 100 % sensitivity and 76.9 % specificity at an optimal cut-off point of 69.6 mg/dL. Among all four machine learning models, random forest outperformed the others and also showed better results than fluid lactate. A newly constructed random forest model, created using 6 of the 13 identified features, displayed promising results in diagnosing NSTI, having a sensitivity and specificity of 90.2 % and 92.2 %, respectively. Conclusions: Developing a diagnostic model for NSTI employing the random forest algorithm has resulted in a diagnostic technique that is more efficient, cost-effective, and expedient. This approach could provide healthcare practitioners with the tools to identify and manage NSTI with greater efficacy.

Mapping the CP-Transgene Insert in the Papaya Genome and Developing a Hermaphrodite Transgenic Hybrid with Broad-Spectrum Resistance to Papaya Ringspot Virus.

Papaya ringspot virus (PRSV) limits papaya production worldwide. Previously, we generated transgenic lines of hybrid Tainung No.2 (TN-2) carrying the coat protein (CP) gene of PRSV with broad resistance to PRSV strains. Unfortunately, all of them were female, unacceptable for growers and consumers in practical applications. With our reported flanking sequences and the newly released papaya genomic information, the CP-transgene insert was identified at a non-coding region in chromosome 3 of the papaya genome, and the flanking sequences were verified and extended. The female transgenic line 16-0-1 was first used for backcrossing with the parental Sunrise cultivar six times and then followed by selfing three times. With multi-level molecular markers developed from the PRSV CP transgene and the genomic flanking sequences, the presence and zygosity of the CP transgene were characterized at the seedling stage. Meanwhile, hermaphrodite genotype was identified by a sex-linked marker. With homozygotic transgene and horticultural properties of Sunrise, a selected hermaphrodite individual was propagated by tissue culture (TC) and used as maternal progenitor to cross with non-transgenic parental cultivar Thailand to generate a new hybrid cultivar TN-2 with a hemizygotic CP-transgene. Three selected hermaphrodite individuals of transgenic TN were micropropagated by TC, and they showed broad-spectrum resistance to different PRSV strains from Taiwan, Hawaii, Thailand, and Mexico under greenhouse conditions. The selected clone TN-2 #1, with excellent horticultural traits, also showed complete resistance to PRSV under field conditions. These selected TC clones of hermaphrodite transgenic TN-2 provide a novel cultivation system in Taiwan and elsewhere.

Unreliable diagnostic accuracy of laboratory risk indicator for necrotizing fasciitis (LRINEC) score but good outcome predictor in necrotizing fasciitis due to Vibrio vulnificus : A retrospective and matched-pair study.

The diagnostic accuracy of laboratory risk indicator for necrotizing fasciitis (LRINEC) score system in specific Vibrio vulnificus (V vulnificus ) necrotizing fasciitis (NF) have not been fully investigated yet. This aim of our study is to validate the LRINEC score in patients with V vulnificus NF. A retrospective study of hospitalized patients was conducted in a hospital in southern Taiwan between January 2015 and December 2022. Clinical characteristics, variables and outcomes were compared among V vulnificus NF, non- Vibrio NF and cellulitis patients. A total of 260 patients were included, 40 in V vulnificus NF group, 80 in non- Vibrio NF group and 160 patients in cellulitis group. In V vulnificus NF group with an LRINEC cutoff score ≥ 6, the sensitivity was 35% (95% confidence interval [CI]: 29%-41%), specificity was 81% (95% CI: 76%-86%), PPV was 23% (95% CI: 17%-27%), and NPV was 90% (95% CI: 88%-92%). The AUROC for accuracy of the LRINEC score in V vulnificus NF was 0.614 (95% CI: 0.592-0.636). Multi-variable logistic regression analysis revealed that LRINEC > 8 was significantly associated with higher in-hospital mortality (adjusted odds ratio = 1.57; 95% CI: 1.43-2.08; P < .01). The LRINEC score may not be an accurate tool for V vulnificus NF. That should be used with caution as a routine diagnostic tool. However, LRINEC > 8 is significantly associated with higher mortality in V vulnificus NF patients.

Predictor of gram-negative bacteremia in cirrhotic patients with skin and soft-tissue infections.

Cirrhosis always goes with profound immunity compromise, and makes those patients easily be the target of skin and soft-tissue infections (SSTIs). Cirrhotic patients with SSTIs have a dramatically increased mortality. To recognize the risk factors of gram-negative infections are critical for improving survival rate. A retrospective cohort study of hospitalized cirrhotic patients with SSTIs and gram-negative bacteremia (GNB) was conducted in 2 tertiary hospitals in southern Taiwan between March 2015 and January 2020. Another group were matched by controls with non-GNB based on time, demographics and immune status. Data such as infectious location, comorbidities, and laboratory findings were recorded and compared. Receiver operating curve and the area under the curve were used to evaluate its discriminating ability. A total of 186 patients were included, 62 in GNB group and 124 in non-GNB group. Comorbidities that were significant risk factors for gram-negative bacteremia included acute kidney injury. Significant risk factors evident in laboratory evaluations included higher model for end-stage liver disease score, higher serum lactate, higher C-reactive protein and higher creatinine level. This study found acute kidney injury, or those exhibiting hyperlactatemia (>16 mg/dL), high MELD score (>14), high CRP (>50 mg/dL), and high creatinine (>2.0 mg/dL) were risk factors associated with gram-negative bacteremia. Cirrhotic patients with SSTIs with aforementioned risk factors should pay more attention by clinicians due to higher mortality.

Comparison of National Early Warning Score with shock index in patients with necrotizing fasciitis.

Shock index (SI) and national early warning score (NEWS) are more frequently used as assessment tools in acute illnesses, patient disposition and early identification of critical condition. Both they are consisted of common vital signs and parameters including heart rate, systolic blood pressure, respiratory rate, oxygen saturation and level of conscious, which made it easy to evaluate in medical facilities. Its ability to predict mortality in patients with necrotizing fasciitis (NF) in the emergency department remains unclear. This study was conducted to compare the predictive capability of the risk scores among NF patients. A retrospective cohort study of hospitalized patients with NF was conducted in 2 tertiary teaching hospitals in Taiwan between January 2013 and March 2015. We investigated the association of NEWS and SI with mortality in NF patients. Of the 395 NF patients, 32 (8.1%) died in the hospital. For mortality, the area under the receiver curve value of NEWS (0.81, 95% confidence interval 0.76-0.86) was significantly higher than SI (0.76, 95% confidence interval 0.73-0.79, P = .016). The sensitivities of NEWS of 3, 4, and 5 for mortality were 98.1%, 95.6%, and 92.3%. On the contrast, the sensitivities of SI of 0.5, 0.6, and 0.7 for mortality were 87.8%, 84.7%, and 81.5%. NEWS had advantage in better discriminative performance of mortality in NF patients. The NEWS may be used to identify relative low risk patients among NF patients.

Correction: Prospective Validation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score for Necrotizing Fasciitis of the Extremities.

[This corrects the article DOI: 10.1371/journal.pone.0227748.].

In-hospital mortality associated with necrotizing soft tissue infection due to Vibrio vulnificus: a matched-pair cohort study.

BACKGROUND: It remains unclear whether Vibrio vulnificus necrotizing soft tissue infection (NSTI) is associated with higher mortality compared with non-Vibrio NSTI. This study's objective was to compare outcomes including in-hospital mortality and prognosis between patients with V. vulnificus NSTI and those with non-Vibrio NSTI. METHOD: A retrospective 1:2 matched-pair cohort study of hospitalized patients with NSTI diagnosed by surgical finding was conducted in two tertiary hospitals in southern Taiwan between January 2015 and January 2020. In-hospital outcomes (mortality, length of stay) were compared between patients with and without V. vulnificus infection. We performed multiple imputation using chained equations followed by multivariable regression analyses fitted with generalized estimating equations to account for clustering within matched pairs. All-cause in-hospital mortality and length of stay during hospitalization were compared for NSTI patients with and without V. vulnificus. RESULT: A total of 135 patients were included, 45 in V. vulnificus NSTI group and 90 in non-Vibrio group. The V. vulnificus NSTI patients had higher mortality and longer hospital stays. Multivariable logistic regression analysis revealed that V. vulnificus NSTI was significantly associated with higher in-hospital mortality compared with non-Vibrio NSTI (adjusted odds ratio = 1.52; 95% confidence interval 1.36-1.70; p < 0.01). CONCLUSION: Vibrio vulnificus NSTI was associated with higher in-hospital mortality and longer hospital stay which may increase health care costs, suggesting that preventing V. vulnificus infection is essential.

Differentiating necrotizing soft tissue infections from cellulitis by soft tissue infectious fluid analysis: a pilot study.

BACKGROUND: We conducted this study to evaluate the characteristics of the infectious fluid in soft tissue infection and investigate the utility of the biochemical tests and Gram stain smear of the infectious fluid in distinguishing necrotizing soft tissue infection (NSTI) from cellulitis. METHODS: This retrospective cohort study was conducted in a tertiary care hospital in Taiwan. From April 2019 to October 2020, patients who were clinically suspected of NSTI with infectious fluid accumulation along the deep fascia and received successful ultrasound-guided aspiration were enrolled. Based on the final discharge diagnosis, the patients were divided into NSTI group, which was supported by the surgical pathology report, or cellulitis group. The t test method and Fisher's exact test were used to compare the difference between two groups. The receiver-operator characteristic (ROC) curves and area under the ROC curve (AUC) were used to evaluate the discriminating ability. RESULTS: Total twenty-five patients were enrolled, with 13 patients in NSTI group and 12 patients in cellulitis group. The statistical analysis showed lactate in fluid (AUC = 0.937) and LDH in fluid (AUC = 0.929) had outstanding discrimination. The optimal cut-off value of fluid in lactate was 69.6 mg/dL with corresponding sensitivity of 100% and specificity of 76.9%. The optimal cut-off value of fluid in LDH was 566 U/L with corresponding sensitivity of 83.3% and a specificity of 92.3%. In addition, albumin in fluid (AUC = 0.821), TP in fluid (AUC = 0.878) and pH in fluid (AUC = 0.858) also had excellent diagnostic accuracy for NSTI. The Gram stain smear revealed 50% bacteria present in NSTI group and all the following infectious fluid culture showed bacteria growth. CONCLUSIONS: The analysis of infectious fluid along the deep fascia might provide high diagnostic accuracy to differentiate NSTI from cellulitis.

Differentiating Lower Extremity Necrotizing Soft Tissue Infection from Severe Cellulitis by Laboratory Parameters and Relevant History Points.

BACKGROUND: Necrotizing soft tissue infection (NSTI) of the lower extremity (LE) is a rapidly progressing infection that requires early diagnosis and prompt treatment to decrease risks of loss of limb or life. Clinical presentation, particularly of early NSTI, can appear similar to severe cellulitis. The purpose of this study is to identify factors that are associated with NSTI rather than severe cellulitis to differentiate patients with similar clinical presentation. METHODS: This retrospective cohort design study compares patients finally diagnosed with LE NSTI versus those diagnosed with severe cellulitis. Cohorts were matched using the modified Laboratory Risk Indicator for Necrotizing Fasciitis (m-LRINEC) score in the setting of LE soft tissue infection. Laboratory values, vital signs, subjective symptoms, and social factors including substance abuse were recorded. Univariate and multivariate analyses were performed. RESULTS: Multivariate statistical analysis and clinical interpretation of data identified four factors more associated with a diagnosis of NSTI than severe cellulitis: elevated lactate, a patient-reported history of fever, male gender, and intravenous substance user. CONCLUSION: In patients with lower extremity infections, the clinical presentation of NSTI and severe cellulitis may appear similar. In this retrospective cohort of patients matched with m-LRINEC scores, elevated lactate, subjective fever, male gender, and intravenous substance abuser were significantly associated with NSTI rather than severe cellulitis. Further studies of these factors in the clinical setting can help tailor the differential diagnosis in the care of patients with severe lower extremity infections. Matched with m-LRINEC scores, elevated lactate, subjective fever, male gender, and intravenous substance abuser were significantly associated with NSTI rather than severe cellulitis. Further studies of these factors in the clinical setting can help tailor the differential diagnosis in the care of patients with severe lower extremity infections.

Utility of the Lactate/Albumin Ratio as a Predictor for Mortality in Necrotizing Fasciitis Patients.

BACKGROUND: The lactate/albumin (L/A) ratio has been proposed as a prognostic marker because the ratio is associated with multiple organ failure and mortality in critically ill patients. We aimed to investigate the clinical utility of the L/A ratio as a good prognostic indicator of mortality in a cohort of necrotizing fasciitis patients. METHOD: This retrospective study was conducted in two tertiary hospitals in Taiwan between 2015 and 2020. We reviewed adult patients with measured serum lactate and albumin on the emergency department (ED) arrival to evaluate the prognostic performance of the lactate and lactate/albumin (L/A) ratio for outcome prediction. RESULT: Of the 262 NF patients, 20 (7.63%) died in the hospital. The area under the receiver operating characteristic curve (AUROC) value of the L/A ratio (0.76, 95% confidence interval [CI] 0.69-0.81, P < 0.01) was higher than lactate alone (0.71, 95% CI 0.65-0.74 P < 0.01) for predicting in-hospital mortality. The optimal cutoff of the L/A ratio was 1.61. The AUROC value of the L/A ratio was better than lactate alone regardless of normal lactate level. The cutoff of L/A ratio and hypoalbuminemia showed further discriminative value for in-hospital mortality even in patients with normal lactate levels. CONCLUSION: The prognostic performance of the L/A ratio was superior to a single measurement of lactate for predicting in-hospital mortality and intensive care unit (ICU) lengths in necrotizing fasciitis patients. Aggressive intervention and intensive care were necessary for high-risk NF patients upon ED arrival.

Utility of modified Laboratory Risk Indicator for Necrotizing Fasciitis (MLRINEC) score in distinguishing necrotizing from non-necrotizing soft tissue infections.

BACKGROUND: We conducted this study to promote a modified Laboratory Risk Indicator for Necrotizing Fasciitis (MLRINEC) score and evaluate the utility in distinguishing necrotizing fasciitis (NF) from other soft-tissue infections. METHOD: A retrospective cohort study of hospitalized patients with NF diagnosed by surgical finding was conducted in two tertiary hospital in southern Taiwan between January 2015 and January 2020. Another group was matched by controls with non-necrotizing soft tissue infections based on time, demographics, and immune status. Data such as infectious location, comorbidities, and laboratory findings were recorded and compared. Logistics regression were used to determine the association with NF after adjustment for confounders and MLRINEC score was developed by then. Receiver operating curve (ROC) and the area under the curve (AUC) were used to evaluate its discriminating ability. RESULT: A total of 303 patients were included; 101 in NF group and 202 in non-NF group. We added serum lactate and comorbid liver disease to the original LRINEC score and re-defined the cut-off values for 3 variables to develop the MLRINEC score. The cut-off value for MLRINEC score was 12 points with corresponding sensitivity of 91.8% and a specificity of 88.4%, and the area under ROC (AUC) was 0.893 (95% CI, 0.723 to 0.948; p < 0.01). CONCLUSION: MLRINEC score shows a high sensitivity and specificity in distinguishing NF from non-necrotizing soft-tissue infections. Patients with a MLRINEC score > 12 points should be highly suspected of presence of necrotizing fasciitis.

Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: A systematic review and meta-analysis.

BACKGROUND: Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest. METHODS: We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system. RESULTS: We included 7 observational studies with a total of 4877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25-0.63, p value = 0.0003). There were insufficient studies for 24-h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the "before 2010" subgroup (OR 0.47; 95% CI 0.30-0.73; p value = 0.006) and the "after 2010" subgroup (OR 0.46; 95% CI 0.25-0.87; p value = 0.02). The certainty of evidence ranged from very low to low. CONCLUSIONS: This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations. TRIAL REGISTRATION: The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).

Serological relationship between Melon yellow spot virus and Watermelon silver mottle virus and differential detection of the two viruses in cucurbits.

Melon yellow spot virus (MYSV), a tentative member of the genus Tospovirus, is considered a distinct serotype due to the lack of a serological relationship with other tospoviruses in its nucleocapsid protein (NP). Recently, a virus isolate collected from diseased watermelon in central Taiwan (MYSV-TW) was found to react with a rabbit antiserum (RAs) prepared against the NP of Watermelon silver mottle virus (WSMoV), and a monoclonal antibody (MAb) prepared against the common epitope of the NSs proteins of WSMoV-serogroup tospoviruses, but not with the WSMoV NP-specific MAb, in both enzyme-linked immunosorbent assay (ELISA) and western blotting. In this investigation, both RAs and MAb against MYSV-TW NP were produced. Results of serological tests revealed that the RAs to MYSV-TW NP reacted with the homologous antigen and the crude antigens of members of the WSMoV serogroup, including members of the formal species WSMoV and Peanut bud necrosis virus, and members of three tentative species, Watermelon bud necrosis virus, Capsicum chlorosis virus and Calla lily chlorotic spot virus. The MAb to MYSV-TW NP reacted only with the homologous antigen and the other geographic isolates of MYSV from Japan (JP) and Thailand (TH). Our results of reciprocal tests indicate that the NP and the NSs protein of MYSV are serologically related to those of WSMoV-serogroup tospoviruses. Furthermore, we show that both the MYSV NP MAb and the WSMoV NP MAb are reliable tools for identification of MYSV and WSMoV from single or mixed infection in field surveys, as verified using species-specific primers in reverse transcription-polymerase chain reaction.

Prospective Validation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score for Necrotizing Fasciitis of the Extremities.

OBJECTIVES: The Laboratory Risk Indicator for Necrotizing Fasciitis score was developed as a clinical decision tool for distinguishing necrotizing fasciitis from other soft tissue infections. We prospectively evaluated the performance of the Laboratory Risk Indicator for Necrotizing Fasciitis score for the diagnosis of patients with necrotizing fasciitis in the extremities. METHODS: We conducted a prospective and observational cohort study of emergency department patients with necrotizing fasciitis or severe cellulitis in the extremities between April 2015 and December 2016. The Laboratory Risk Indicator for Necrotizing Fasciitis score was calculated for every enrolled patient. The sensitivity, specificity, positive predictive value, and negative predictive value of cut-off scores of 6 and 8 were evaluated. The accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was expressed as the area under the receiver operating characteristic curve. RESULTS: A total of 106 patients with necrotizing fasciitis and 825 patients with cellulitis were included. With an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥6, the sensitivity was 43% (95% confidence interval 34% to 53%), specificity was 83% (95% confidence interval 80% to 86%), positive predictive value was 25% (95% confidence interval 20% to 30%), and negative predictive value was 92% (95% confidence interval 91% to 93%); with an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥8, the sensitivity was 27% (95% confidence interval 19% to 37%), specificity was 93% (95% confidence interval 91% to 94%), positive predictive value was 33% (95% confidence interval 25% to 42%), and negative predictive value was 91% (95% confidence interval 90% to 92%). The area under the receiver operating characteristic curve for accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was 0.696 (95% CI 0.640 to 0.751). CONCLUSION: The Laboratory Risk Indicator for Necrotizing Fasciitis score may not be an accurate tool for necrotizing fasciitis risk stratification and differentiation between severe cellulitis and necrotizing fasciitis in the emergency department setting based on our study.

Clinical predictors and impact of bacteremia in cirrhotic patients with acute skin and skin structure infection.

OBJECTIVE: Acute bacterial skin and skin structure infection (ABSSSI) is a common cause of acute admissions in patients with cirrhosis worldwide, but the disease is not well-understood epidemiologically with respect to factors that determine positive blood cultures or patient mortality. The aim of this study was to understand the utility of blood cultures and the association between bacteremia and mortality in cirrhotic patients with ABSSSI. We conducted a retrospective study to investigate factors associated with positive blood cultures and mortality in cirrhotic patients with ABSSSI. METHODS: A retrospective cohort study of hospitalized adult cirrhotic patients with ABSSSI was conducted in a tertiary hospital in Taiwan between March 2015 and December 2016. RESULTS: A total of 122 hospitalized cirrhotic patients with ABSSSI were included. The overall mortality rate was 9% (11/122), and 23 patients had positive blood culture results. Comorbidities that were significant risk factors for a positive blood culture included diabetes mellitus, acute kidney injury (AKI), and acute-on-chronic liver failure (ACLF). Significant risk factors evident in laboratory evaluations included higher model for end-stage liver disease (MELD) score, higher serum lactate, and lower serum albumin level. Bacteremia was also a significant factor associated with mortality. CONCLUSION: A blood culture should be considered for cirrhotic patients with ABSSSI with diabetes mellitus, AKI, ACLF or those exhibiting abnormal albumin, lactate levels, or high MELD score because of the positive correlation between bacteremia and mortality.