Dataset Information

The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study.

ABSTRACT:

Background

There is a lack of validated tools to assess potential disease progression and hospitalisation decisions in patients presenting to the emergency department (ED) with a suspected infection. This study aimed to identify suitable blood biomarkers (MR-proADM, PCT, lactate and CRP) or clinical scores (SIRS, SOFA, qSOFA, NEWS and CRB-65) to fulfil this unmet clinical need.

Methods

An observational derivation patient cohort validated by an independent secondary analysis across nine EDs. Logistic and Cox regression, area under the receiver operating characteristic (AUROC) and Kaplan-Meier curves were used to assess performance. Disease progression was identified using a composite endpoint of 28-day mortality, ICU admission and hospitalisation > 10 days.

Results

One thousand one hundred seventy-five derivation and 896 validation patients were analysed with respective 28-day mortality rates of 7.1% and 5.0%, and hospitalisation rates of 77.9% and 76.2%. MR-proADM showed greatest accuracy in predicting 28-day mortality and hospitalisation requirement across both cohorts. Patient subgroups with high MR-proADM concentrations (≥ 1.54 nmol/L) and low biomarker (PCT < 0.25 ng/mL, lactate < 2.0 mmol/L or CRP < 67 mg/L) or clinical score (SOFA < 2 points, qSOFA < 2 points, NEWS < 4 points or CRB-65 < 2 points) values were characterised by a significantly longer length of hospitalisation (p < 0.001), rate of ICU admission (p < 0.001), elevated mortality risk (e.g. SOFA, qSOFA and NEWS HR [95%CI], 45.5 [10.0-207.6], 23.4 [11.1-49.3] and 32.6 [9.4-113.6], respectively) and a greater number of disease progression events (p < 0.001), compared to similar subgroups with low MR-proADM concentrations (< 1.54 nmol/L). Increased out-patient treatment across both cohorts could be facilitated using a derivation-derived MR-proADM cut-off of < 0.87 nmol/L (15.0% and 16.6%), with decreased readmission rates and no mortalities.

Conclusions

In patients presenting to the ED with a suspected infection, the blood biomarker MR-proADM could most accurately identify the likelihood of further disease progression. Incorporation into an early sepsis management protocol may therefore aid rapid decision-making in order to either initiate, escalate or intensify early treatment strategies, or identify patients suitable for safe out-patient treatment.

SUBMITTER: Saeed K

PROVIDER: S-EPMC6368690 | biostudies-literature | 2019 Feb

REPOSITORIES: biostudies-literature

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Publications

The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study.

Saeed Kordo K Wilson Darius Cameron DC Bloos Frank F Schuetz Philipp P van der Does Yuri Y Melander Olle O Hausfater Pierre P Legramante Jacopo M JM Claessens Yann-Erick YE Amin Deveendra D Rosenqvist Mari M White Graham G Mueller Beat B Limper Maarten M Callejo Carlota Clemente CC Brandi Antonella A Macchi Marc-Alexis MA Cortes Nicholas N Kutz Alexander A Patka Peter P Yañez María Cecilia MC Bernardini Sergio S Beau Nathalie N Dryden Matthew M van Gorp Eric C M ECM Minieri Marilena M Chan Louisa L Rood Pleunie P M PPM Del Castillo Juan Gonzalez JG

Critical care (London, England) 20190208 1

<h4>Background</h4>There is a lack of validated tools to assess potential disease progression and hospitalisation decisions in patients presenting to the emergency department (ED) with a suspected infection. This study aimed to identify suitable blood biomarkers (MR-proADM, PCT, lactate and CRP) or clinical scores (SIRS, SOFA, qSOFA, NEWS and CRB-65) to fulfil this unmet clinical need.<h4>Methods</h4>An observational derivation patient cohort validated by an independent secondary analysis across ...[more]

PMID: 30736862

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Project description:ImportanceProfessional guidelines recommend noninvasive cardiac testing (NIT) within 72 hours of an emergency department (ED) evaluation for suspected acute coronary syndrome. However, there is inexact evidence that this strategy reduces the risk of future death or acute myocardial infarction (MI).ObjectiveTo evaluate the effectiveness of early NIT in reducing the risk of death or acute MI within 30 days.Design, setting, and participantsThis retrospective, multicenter cohort study within the Kaiser Permanente Southern California integrated health care delivery system compared the effectiveness of early noninvasive cardiac testing vs no testing in patients with chest pain and in whom acute MI was ruled out who presented to an ED from January 2015 to December 2017. Patients were followed up for up to 30 days after emergency department discharge.ExposuresNoninvasive cardiac testing performed within 3 days of an ED evaluation for suspected acute coronary syndrome.Main outcomes and measuresThe primary outcome was composite risk of death or acute MI, within 30 days of an ED discharge.ResultsA total of 79 040 patients were evaluated in this study, of whom 57.7% were female. The mean (SD) age of the cohort was 57 (16) years, and 16 164 patients (21%) had completed early NIT. The absolute risk of death or MI within 30 days was low (<1%). Early NIT had the minor benefit of reducing the absolute composite risk of death or MI (0.4% [95% CI, -0.6% to -0.3%]), and, separately, of death (0.2% [95% CI, -0.2% to -0.1%]), MI (-0.3% [95% CI, -0.5% to -0.1%]), and major adverse cardiac event (-0.5% [95% CI, -0.7% to -0.3%]). The number needed to treat was 250 to avoid 1 death or MI, 500 to avoid 1 death, 333 to avoid 1 MI, and 200 to avoid 1 major adverse cardiovascular event within 30 days. Subgroup analysis revealed a number needed to treat of 14 to avoid 1 death or MI in the subset of patients with elevated troponin.Conclusions and relevanceEarly NIT was associated with a small decrease in the risk of death or MI in patients admitted to the ED with suspected acute coronary syndrome, but this clinical strategy may not be optimal for most patients given the large number needed to treat.

Dataset Information

The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study.

Background

Methods

Results

Conclusions

Publications

The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study.

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