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The article discusses the challenges in diagnosing sepsis and the need for biomarkers that can be used in the emergency department (ED) to rapidly identify high-risk patients. A study conducted in German tertiary hospitals tested the performance of various biomarkers, with procalcitonin performing the best in identifying patients with sepsis. However, the accuracy of procalcitonin was still moderate, and other promising biomarkers were not tested in this study. The study suggests that while procalcitonin testing can be used in selected patients with suspected sepsis, it should not override clinical judgment. The study provides preliminary data for future trials examining the impact of biomarkers on clinical management and patient outcomes. [Extracted from the article]

Introduction: Sepsis is a life-threatening condition with a very narrow golden period in which confirmatory diagnosis may change the outcome dramatically. No confirmatory biomarker is available till date for early diagnosis of sepsis. This study aimed to evaluate the combined and independent role of quick sequential organ failure assessment (qSOFA) score, lactate, and neutrophil–lymphocyte ratio (NLR) in diagnosis and mortality prediction in early sepsis. Methods: This was a hospital-based, single-center, prospective cohort study conducted in a tertiary care institute, Karnataka, India. Three hundred adult sepsis patients were recruited during 10-month period, and demographic data, qSOFA score, lactate, NLR, and culture samples were collected in ED within 1 h of admission. Outcome groups (survivor and nonsurvivor) were statistically analyzed with relative frequencies (%), median, mean ± standard deviation with 95% confidence interval (CI), univariate, bivariate, and multivariate logistic regression analysis, and Receiver -operating characteristic curve (ROC) curve to test the predictive ability of initial levels of three biomarkers. Results: Sepsis was more prevalent among middle-aged male patients. Male gender (odds ratio [OR], 6.9; 95% CI: 1.61–30.1), qSOFA (OR, 154; 95% CI: 15–1565), and lactate (OR, 1.36; 95% CI: 22–833) show 97% (area under the curve) predictive accuracy of the model for sepsis on bivariate and multivariate logistic regression analysis. A significant rise in NLR was a poor outcome indicator on univariate analysis (P = 0.773). Conclusion: All three biomarkers are good outcome predictors whereas qSOFA and lactate have diagnostic significance in early sepsis. These markers can be used for patient triaging, minimizing culture report dependence for treatment and ultimately the outcome. [ABSTRACT FROM AUTHOR]

Objective: Several scoring systems have been proposed for EDs to identify patients at increased risk of mortality from sepsis. The modified Sequential Organ Failure Assessment (mSOFA) score, proposed in 2019, demonstrated a high negative predictive value. We aimed to validate mSOFA and compare its accuracy for predicting 30‐day mortality to the simple bedside score, quick SOFA (qSOFA). Methods: Over 1 month in 2018, consecutive patients with suspected sepsis were prospectively identified. A retrospective chart review was conducted to calculate both the mSOFA and qSOFA scores for these patients. The primary outcome was 30‐day mortality. Results: There were 252 patients with suspected sepsis identified over the study period. Thirty‐day mortality was 13/39 (33.3%) for those with a positive mSOFA and 15/211 (7.1%) for those with a negative mSOFA score. Sensitivity was 46.4% (95% confidence interval [CI] 27.5–66.1%), specificity 88.3% (95% CI 83.3–92.2%), positive likelihood ratio 3.96 (95% CI 2.32–6.78), negative likelihood ratio 0.61 (95% CI 0.43–0.86). The area under the curve (AUC) was 0.74 (95% CI 0.64–0.85). qSOFA sensitivity was 39.3% (95% CI 21.5–59.4%), specificity 91.9% (95% CI 87.5–95.1%), positive likelihood ratio 4.85 (95% CI 2.56–9.18) and negative likelihood ratio 0.66 (95% CI 0.49–0.89). The AUC for qSOFA was 0.81 (95% CI 0.73–0.88). The difference in the AUC was −0.07 (95% CI −0.18 to 0.05), P = 0.25. Conclusions: In the present study, neither mSOFA nor qSOFA was adequately sensitive for predicting 30‐day mortality, although both scores were highly specific and their overall accuracy was similar. The added complexity of the mSOFA without a significant increase in discriminative ability makes it unlikely to replace qSOFA in the ED setting. [ABSTRACT FROM AUTHOR]

Background: Bacterial sepsis is associated with significant morbidity and mortality. However, to date, there is no single test that predicts sepsis with reproducible results. We proposed that using a combination of clinical and laboratory parameters and a novel biomarker, plasma neutrophil gelatinase-associated lipocalin (NGAL) may aid in early diagnosis. Method: A prospective cohort study was conducted at a tertiary care center in South India (June 2017 to April 2018) on patients with acute febrile episodes fulfilling the Systemic Inflammatory Response Syndrome (SIRS) criteria. Plasma NGAL and standard clinical and laboratory parameters were collected at the admission. Bacterial sepsis was diagnosed based on blood culture positivity or clinical diagnosis. Clinically relevant plasma NGAL cut-off values were identified using the receive operating characteristic (ROC) curve. Clinically relevant clinical parameters along with plasma NGAL's risk ratios estimated from the multivariable Poisson regression model were rounded and used as weights to create a new scoring tool. Results: Of 100 patients enrolled, 37 had bacterial sepsis. The optimal plasma NGAL cut-off value to predict sepsis was 570 ng/mL [area under the curve (AUC): 0.69]. The NGAL sepsis screening tool consists of the following clinical parameter: diabetes mellitus, the presence of rigors, quick sequential organ failure assessment (qSOFA) >2, a clear focus of infection, and the plasma NGAL >570 ng/mL. A score of <3 ruled out bacterial sepsis and a score >7 were highly suggestive of bacterial sepsis with an interval likelihood ratio (LR) of 7.77. Conclusion: The NGAL sepsis screening tool with a score >7 can be used in the emergency department (ED) to identify bacterial sepsis. [ABSTRACT FROM AUTHOR]

Introduction: Sepsis is the leading cause of mortality, and various scoring systems have been developed for its early identification and treatment. The objective was to test the ability of quick sequential organ failure assessment (qSOFA) score to identify sepsis and predict sepsis-related mortality in the emergency department (ED). Methods: We conducted a prospective study from July 2018 to April 2020. Consecutive patients with age ≥18 years who presented to the ED with a clinical suspicion of infection were included. Sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and odds ratio (OR) for sepsis related mortality on day 7 and 28 were measured. Results: A total of 1200 patients were recruited; of which 48 patients were excluded and 17 patients were lost to follow-up. 54 (45.4%) of 119 patients with positive qSOFA (qSOFA >2) died at 7 days and 76 (63.9%) died at 28 days. A total of 103 (10.1%) of 1016 patients with negative qSOFA (qSOFA score <2) died at 7 days and 207 (20.4%) died at 28 days. Patients with positive qSOFA score were at higher odds of dying at 7 days (OR: 3.9, 95% confidence interval [CI]: 3.1–5.2, P < 0.001) and 28 days (OR: 6.9, 95% CI: 4.6–10.3, P < 0.001). The PPV and NPV with positive qSOFA score to predict 7- and 28-day mortality were 45.4%, 89.9% and 63.9%, 79.6%, respectively. Conclusion: The qSOFA score can be used as a risk stratification tool in a resource-limited setting to identify infected patients at an increased risk of death. [ABSTRACT FROM AUTHOR]

Background: High in-hospital mortality in sepsis patients remains challenging for clinicians worldwide. Early recognition, prognostication, and aggressive management are essential for treating septic patients. Many scores have been formulated to guide clinicians to predict the early deterioration of such patients. Our objective was to compare predictive values of quick Sequential Organ Failure Assessment (qSOFA) and National Early Warning Score 2 (NEWS2) with respect to in-hospital mortality. Methods: This prospective observational study was conducted in a tertiary care center in India. Adults with suspected infection with at least two Systemic Inflammatory Response Syndrome criteria presenting to the emergency department (ED) were enrolled. NEWS2 and qSOFA scores were calculated, and patients were followed until their primary outcome of mortality or hospital discharge. The diagnostic accuracy of qSOFA and NEWS2 for predicting mortality was analyzed. Results: Three hundred and seventy-three patients were enrolled. Overall mortality was 35.12%. A majority of patients had LOS between 2 and 6 days (43.70%). NEWS2 had higher area under curve at 0.781 (95% confidence interval [CI] (0.59, 0.97)) than qSOFA at 0.729 (95% CI [0.51, 0.94]), with P < 0.001. Sensitivity, specificity, and diagnostic efficiency to predict mortality by NEWS2 were 83.21% (95% CI [83.17%, 83.24%]); 57.44% (95% CI [57.39%, 57.49%]); and 66.48% (95% CI [66.43%, 66.53%]), respectively. qSOFA score had sensitivity, specificity, and diagnostic efficiency to predict mortality of 77.10% (95% CI [77.06%, 77.14%]); 42.98% (95% CI [42.92%, 43.03%]); and 54.95% (95% CI [54.90%, 55.00%]), respectively. Conclusion: NEWS2 is superior to qSOFA in predicting in-hospital mortality for sepsis patients presenting to the ED in India. [ABSTRACT FROM AUTHOR]

Purpose: There are conflicting data regarding the role of the National Early Warning Score 2 (NEWS2) in predicting adverse outcomes in patients with infectious diseases. New-onset atrial fibrillation (NO-AF) has been suggested as a sepsis-defining sign of organ dysfunction. This study aimed to examine the prognostic accuracy of NEWS2 and whether NO-AF can provide prognostic information in emergency department (ED) patients with suspected bacterial infections. Patients and Methods: Secondary analyses of data from a prospective observational cohort study of adults admitted in a 6-month period with suspected bacterial infections. We used the composite endpoint of in-hospital mortality or transfer to the intensive care unit as the primary outcome. The prognostic accuracy of NEWS2 and quick sequential organ failure assessment (qSOFA) and covariate-adjusted area under the receiver operating curves (AAUROC) were used to describe the performance of the scores. Logistic regression analysis was used to examine the association between NO-AF and the composite endpoint. Results: A total of 2055 patients were included in this study. The composite endpoint was achieved in 198 (9.6%) patients. NO-AF was observed in 80 (3.9%) patients. The sensitivity and specificity for NEWS2 ≥ 5 were 70.2% (63.3– 76.5) and 60.2% (57.9– 62.4), respectively, and those for qSOFA ≥ 2 were 26.3% (20.3– 33.0) and 91.0% (89.6– 92.3), respectively. AAUROC for NEWS2 and qSOFA were 0.68 (0.65– 0.73) and 0.63 (0.59– 0.68), respectively. The adjusted odds ratio for achieving the composite endpoint in 48 patients with NO-AF who fulfilled the NEWS2 ≥ 5 criteria was 2.71 (1.35– 5.44). Conclusion: NEWS2 had higher sensitivity but lower specificity and better, albeit poor, discriminative ability to predict the composite endpoint compared to qSOFA. NO-AF can provide important prognostic information. [ABSTRACT FROM AUTHOR]

Background: Sepsis is a disease with a high mortality rate without prompt treatment. However, this entity is difficult to diagnose in the elderly population in the emergency room; for this reason, it is necessary to have diagnostic tools for early detection. Objective: The aim of the study was to determine the highest diagnostic yield of procalcitonin (PCT), Quick Sequential Organ Failure Assessment (qSOFA), and Sequential Organ Failure Assessment (SOFA) for sepsis (based on the sepsis-3 consensus), on admission at the emergency department, in those older than 65 years. Methods: This is a diagnostic test study of a historical cohort of 65-year-old patients with suspected sepsis. Results: In the sample of 179 patients, 53.6% had confirmed sepsis. Significant differences were found (p < 0.0001), with a greater diagnostic and predictive capacity of PCT for the diagnosis of sepsis (receiver operating characteristics curve area [area under the curve (AUC) = 0.883, 95% CI: 0.835–0.931] than qSOFA (AUC = 0.559, 95% CI: 0.485–0.663) and SOFA (AUC = 0.662, 95% CI: 0.584–0.739); these results were similar in the cohort of patients ≥75 years. In positive PCT(≥0.5 ng/mL), the sensitivity was 71.8% (95% CI: 62.36–81.39), specificity of 89.1% (95% CI: 81.87–96.45%), V+ 88.4% (95% CI: 80.73–96.19%), V− of 73.2% (95% CI: 64.14–82.39%), positive likelihood ratio of 6.63 (95% CI: 3.53–12.44), and negative likelihood ratio of 0.32 (95% CI: 0.23–0.44); these results were similar in the cohort of patients ≥75 years. Lactate ≥2 mmol/L (RR = 1.659 [95% CI: 1.002–2.747]) and PCT ≥0.5 ng/mL (RR = 1.942 [95% CI: 1.157–3.261]) showed a significant association with in-hospital mortality. Conclusion: In the elderly population with suspicion of infection on admission to the emergency department, qSOFA presents a low diagnostic performance of confirmed sepsis and in-hospital mortality, for which other tools with higher diagnostic and prognostic performance should be added, such as PCT and lactate. [ABSTRACT FROM AUTHOR]

Objectives: Biliary tract infection (BTI) is a common cause of bacteremia and is associated with high morbidity and mortality. However, studies on screening tools to predict disease severity in BTI patients are lacking. This study aimed to comparatively validate CRB, CRB-65, quick Sequential Organ Failure Assessment (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS) in predicting the clinical outcomes of BTI patients. Methods: This retrospective cohort study included patients with BTI who visited the emergency department of a medical center between February 2018 and March 2020. Baseline patient data were compared to assess the prevalence of intensive care unit (ICU) admission and in-hospital mortality. The effectiveness of CRB, CRB-65, qSOFA, and SIRS scores as indicators of ICU admission and in-hospital mortality was evaluated using the area under the receiver operating characteristic (AUROC) curve. Results: This study included 745 patients, of whom 111 (14.8%) were admitted to the ICU and 20 (2.7%) died in-hospital. AUROC values (95% CI) for predicting ICU admission and in-hospital mortality were as follows: CRB, 0.774 and 0.707 (0.742 - 0.803 and 0.673 - 0.739); CRB - 65, 0.816 and 0.735 (0.786 - 0.843 and 0.0.702 - 0.766); qSOFA, 0.779 and 0.724 (03747 - 0.808 and 0.690 - 0.755); and SIRS, 0.686 and 0.659 (0.651 - 0.719 and 0.623 - 0.693), respectively. Conclusions: CRB-65 can be used as useful screening tools to predict ICU admission in patients with BTI on presentation to the emergency department. [ABSTRACT FROM AUTHOR]

Objectives: Evaluate the accuracy of the quick Sequential Organ Failure Assessment tool to predict mortality across increasing levels of comorbidity burden.Design: Retrospective observational cohort study.Setting: Twelve acute care hospitals in the Southeastern United States.Patients: A total of 52,187 patients with suspected infection presenting to the Emergency Department between January 2014 and September 2017.Interventions: None.Measurements and Main Results: The primary outcome was hospital mortality. We used electronic health record data to calculate quick Sequential Organ Failure Assessment risk scores from vital signs and laboratory values documented during the first 24 hours. We calculated Charlson Comorbidity Index scores to quantify comorbidity burden. We constructed logistic regression models to evaluate differences in the performance of quick Sequential Organ Failure Assessment greater than or equal to 2 to predict hospital mortality in patients with no documented (Charlson Comorbidity Index = 0), low (Charlson Comorbidity Index = 1-2), moderate (Charlson Comorbidity Index = 3-4), or high (Charlson Comorbidity Index ≥ 5) comorbidity burden. Among the cohort, 2,030 patients died in the hospital (4%). No comorbidities were documented for 5,038 patients (10%), 9,235 patients (18%) had low comorbidity burden, 12,649 patients (24%) had moderate comorbidity burden, and 25,265 patients (48%) had high comorbidity burden. Overall model discrimination for quick Sequential Organ Failure Assessment greater than or equal to 2 was the area under the receiver operating characteristic curve of 0.71 (95% CI, 0.69-0.72). A model including both quick Sequential Organ Failure Assessment and Charlson Comorbidity Index had improved discrimination compared with Charlson Comorbidity Index alone (area under the receiver operating characteristic curve, 0.77; 95% CI, 0.76-0.78 vs area under the curve, 0.61; 95% CI, 0.59-0.62). Discrimination was highest among patients with no documented comorbidities (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.84; 95% CI; 0.79-0.89) and lowest among high comorbidity patients (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.67; 95% CI, 0.65-0.68). The strength of association between quick Sequential Organ Failure Assessment and mortality ranged from 30.5-fold increased likelihood in patients with no comorbidities to 4.7-fold increased likelihood in patients with high comorbidity.Conclusions: The accuracy of quick Sequential Organ Failure Assessment to predict hospital mortality diminishes with increasing comorbidity burden. Patients with comorbidities may have baseline abnormalities in quick Sequential Organ Failure Assessment variables that reduce predictive accuracy. Additional research is needed to better understand quick Sequential Organ Failure Assessment performance across different comorbid conditions with modification that incorporates the context of changes to baseline variables. [ABSTRACT FROM AUTHOR]

Background and Aim: Scrub typhus (ST) is an acute infectious disease of variable severity caused by Orientia (formerly Rickettsia) tsutsugamushi. The disease can be complicated by organ dysfunctions and the case fatality rate (CFR) is approximately 15%, which further rises with the development of severe complications. We studied the clinical features of the ST and the performance of critical illness scoring systems (CISSs) – Acute Physiology and Chronic Health Evaluation (APACHE) II, sequential organ failure assessment (SOFA), and quick SOFA (qSOFA) in predicting the clinical outcomes in complicated ST (cST) patients admitted to the emergency department. Study Design and Methods: A prospective observational study was done in 50 patients diagnosed to have cST with one or more organ dysfunctions. Clinical features and laboratory parameters were recorded and the patients were followed up until the end of their stay in the hospital. APACHE II, SOFA, and qSOFA scores at admission were calculated and were analyzed in predicting the clinical outcomes. Results: The median SOFA, APACHE II, and qSOFA scores of the cohort were 7 (interquartile range [IQR] = 13–22), 8 (IQR = 5–11), and 2 (IQR = 1–3), respectively. The median duration of in-hospital stay was 9 (IQR 5–11) days and overall CFR was 8%. On bivariate analysis, both SOFA (P = 0.031) and qSOFA (P = 0.001) predicted mortality. However, only SOFA score correlated with the in-hospital stay duration (Pearson's correlation = 0.311, P = 0.028). Conclusion: Among the three CISSs studied, the SOFA score correlated with in-hospital stay duration and mortality, whereas the qSOFA score formed a simple as well as a convenient tool in predicting the mortality in patients of cST with organ dysfunction. [ABSTRACT FROM AUTHOR]

Objective: The Third International Consensus Definitions Task Force (Sepsis-3) recently recommended changes to the definitions of sepsis. The impact of these changes remains unclear. Our objective was to determine the outcomes of patients meeting Sepsis-3 septic shock criteria versus patients meeting the "old" (1991) criteria of septic shock only.Design: Secondary analysis of two clinical trials of early septic shock resuscitation.Setting: Large academic emergency departments in the United States.Patients: Patients with suspected infection, more than or equal to two systemic inflammatory response syndrome criteria, and systolic blood pressure less than 90 mm Hg after fluid resuscitation.Interventions: Patients were further categorized as Sepsis-3 septic shock if they demonstrated hypotension, received vasopressors, and exhibited a lactate greater than 2 mmol/L. We compared in-hospital mortality in patients who met the old definition only with those who met the Sepsis-3 criteria.Measurements and Main Results: Four hundred seventy patients were included in the present analysis. Two hundred (42.5%) met Sepsis-3 criteria, whereas 270 (57.4%) met only the old definition. Patients meeting Sepsis-3 criteria demonstrated higher severity of illness by Sequential Organ Failure Assessment score (9 vs 5; p < 0.001) and mortality (29% vs 14%; p < 0.001). Subgroup analysis of 127 patients meeting only the old definition demonstrated significant mortality benefit following implementation of a quantitative resuscitation protocol (35% vs 10%; p = 0.006).Conclusion: In this analysis, 57% of patients meeting old definition for septic shock did not meet Sepsis-3 criteria. Although Sepsis-3 criteria identified a group of patients with increased organ failure and higher mortality, those patients who met the old criteria and not Sepsis-3 criteria still demonstrated significant organ failure and 14% mortality rate. [ABSTRACT FROM AUTHOR]

Background: The study aimed to investigate the predictive value of the quick sequential organ failure assessment (qSOFA) for clinical outcomes in emergency patients with community-acquired pneumonia (CAP).Methods: A total of 742 CAP cases from the emergency department (ED) were enrolled in this study. The scoring systems including the qSOFA, SOFA and CURB-65 (confusion, urea, respiratory rate, blood pressure and age) were used to predict the prognostic outcomes of CAP in ICU-admission, acute respiratory distress syndrome (ARDS) and 28-day mortality. According to the area under the curve (AUC) of the receiver operating characteristic (ROC) curves, the accuracies of prediction of the scoring systems were analyzed among CAP patients.Results: The AUC values of the qSOFA, SOFA and CURB-65 scores for ICU-admission among CAP patients were 0.712 (95%CI: 0.678-0.745, P < 0.001), 0.744 (95%CI: 0.711-0.775, P < 0.001) and 0.705 (95%CI: 0.671-0.738, P < 0.001), respectively. For ARDS, the AUC values of the qSOFA, SOFA and CURB-65 scores were 0.730 (95%CI: 0.697-0.762, P < 0.001), 0.724 (95%CI: 0.690-0.756, P < 0.001) and 0.749 (95%CI: 0.716-0.780, P < 0.001), respectively. After 28 days of follow-up, the AUC values of the qSOFA, SOFA and CURB-65 scores for 28-day mortality were 0.602 (95%CI: 0.566-0.638, P < 0.001), 0.587 (95%CI: 0.551-0.623, P < 0.001) and 0.614 (95%CI: 0.577-0.649, P < 0.001) in turn. There were no statistical differences between qSOFA and SOFA scores for predicting ICU-admission (Z = 1.482, P = 0.138), ARDS (Z = 0.321, P = 0.748) and 28-day mortality (Z = 0.573, P = 0.567). Moreover, we found no differences to predict the ICU-admission (Z = 0.370, P = 0.712), ARDS (Z = 0.900, P = 0.368) and 28-day mortality (Z = 0.768, P = 0.442) using qSOFA or CURB-65 scores.Conclusion: qSOFA was not inferior to SOFA or CURB-65 scores in predicting the ICU-admission, ARDS and 28-day mortality of patients presenting in the ED with CAP. [ABSTRACT FROM AUTHOR]