The comparative ability of commonly used disease severity scores to predict death or a requirement for ICU care in patients hospitalised with possible sepsis in Yangon, Myanmar

Respiratory manifestations of rickettsial disease in tropical Australia; Clinical course and implications for patient management

BACKGROUND

Rickettsial infections have a global distribution and can cause life-threatening disease. Respiratory symptoms can be a harbinger of a more complicated disease course. However, the clinical associations - and the clinical course - of patients with rickettsial disease and respiratory involvement are incompletely defined.

METHODS

This was a retrospective study of all patients with a diagnosis of scrub typhus or Queensland tick typhus (QTT) managed at Cairns Hospital in tropical Australia, between 1st January 1997 and 31st October 2023. We determined the demographic, clinical, radiological and laboratory associations of respiratory involvement which was defined as any acute abnormality of lung parenchyma identified on thoracic imaging during their hospitalisation that did not have another more likely explanation. We compared the clinical course of patients with a rickettsial infection who did - and did not - have respiratory involvement.

RESULTS

There were 226 individuals included in the analysis, 51/226 (22 %) had respiratory involvement, including 18/59 (31 %) with QTT and 33/167 (20 %) with scrub typhus, p = 0.09. The imaging findings were heterogenous: 33/51 (65 %) had predominantly alveolar changes, 18/51 (35 %) had interstitial changes and 12/51 (24 %) had a pleural effusion. Those with respiratory involvement were older than individuals without respiratory involvement (median (interquartile range (IQR)) age 51 (37-65) years versus 38 (25-51) years (p = 0.0001). However, most patients (27/51, 53 %) with respiratory involvement had no comorbidity and were younger than 60. Patients with respiratory involvement were more likely to require ICU admission that patients without respiratory involvement (19/51 (38 %) versus 6/175 (3 %) p < 0.001) and 9/51 (18 %) with respiratory involvement required mechanical ventilation. Patients with respiratory involvement were also more likely to require vasopressor support (14/51, 27 % versus 4/175, 2 %, p < 0.001) and renal replacement therapy (4/51, 8 % versus 1/175, 0.6 %, p = 0.01) than patients without respiratory involvement. There were 2/226 (1 %) individuals who died from their rickettsial infection (1 scrub typhus and 1 QTT) during the study period, both had respiratory involvement.

CONCLUSIONS

Respiratory involvement is common in individuals with rickettsial infection in tropical Australia and is associated with a greater risk of life-threatening disease.

Predicting mortality in febrile adults: comparative performance of the MEWS, qSOFA, and UVA scores using prospectively collected data among patients in four health-care sites in sub-Saharan Africa and South-Eastern Asia

Background

Clinical severity scores can identify patients at risk of severe disease and death, and improve patient management. The modified early warning score (MEWS), the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA), and the Universal Vital Assessment (UVA) were developed as risk-stratification tools, but they have not been fully validated in low-resource settings where fever and infectious diseases are frequent reasons for health care seeking. We assessed the performance of MEWS, qSOFA, and UVA in predicting mortality among febrile patients in the Lao PDR, Malawi, Mozambique, and Zimbabwe.

Methods

We prospectively enrolled in- and outpatients aged ≥ 15 years who presented with fever (≥37.5 °C) from June 2018-March 2021. We collected clinical data to calculate each severity score. The primary outcome was mortality 28 days after enrolment. The predictive performance of each score was determined using area under the receiver operating curve (AUC).

Findings

A total of 2797 participants were included in this analysis. The median (IQR) age was 32 (24-43) years, 38% were inpatients, and 60% (1684/2797) were female. By the time of follow-up, 7% (185/2797) had died. The AUC (95% CI) for MEWS, qSOFA and UVA were 0.67 (0.63-0.71), 0.68 (0.64-0.72), and 0.82 (0.79-0.85), respectively. The AUC comparison found UVA outperformed both MEWS (p < 0.001) and qSOFA (p < 0.001).

Interpretation

We showed that the UVA score performed best in predicting mortality among febrile participants by the time follow-up compared with MEWS and qSOFA, across all four study sites. The UVA score could be a valuable tool for early identification, triage, and initial treatment guidance of high-risk patients in resource-limited clinical settings.

Funding

FCDO.

The Epidemiological, Clinical, and Microbiological Features of Patients with Burkholderia pseudomallei Bacteraemia-Implications for Clinical Management

Patients with melioidosis are commonly bacteraemic. However, the epidemiological characteristics, the microbiological findings, and the clinical associations of Burkholderia pseudomallei bacteraemia are incompletely defined. All cases of culture-confirmed melioidosis at Cairns Hospital in tropical Australia between January 1998 and June 2023 were reviewed. The presence of bacteraemia was determined and correlated with patient characteristics and outcomes; 332/477 (70%) individuals in the cohort were bacteraemic. In multivariable analysis, immunosuppression (odds ratio (OR) (95% confidence interval (CI)): (2.76 (1.21-6.27), p = 0.02), a wet season presentation (2.27 (1.44-3.59), p < 0.0001) and male sex (1.69 (1.08-2.63), p = 0.02), increased the likelihood of bacteraemia. Patients with a skin or soft tissue infection (0.32 (0.19-0.57), p < 0.0001) or without predisposing factors for melioidosis (0.53 (0.30-0.93), p = 0.03) were less likely to be bacteraemic. Bacteraemia was associated with intensive care unit admission (OR (95%CI): 4.27 (2.35-7.76), p < 0.0001), and death (2.12 (1.04-4.33), p = 0.04). The median (interquartile range) time to blood culture positivity was 31 (26-39) hours. Patients with positive blood cultures within 24 h were more likely to die than patients whose blood culture flagged positive after this time (OR (95%CI): 11.05 (3.96-30.83), p < 0.0001). Bacteraemia portends a worse outcome in patients with melioidosis. Its presence or absence might be used to help predict outcomes in cases of melioidosis and to inform optimal clinical management.

A comparison of different scores for diagnosis and mortality prediction of adults with sepsis in Low-and-Middlencome Countries: a systematic review and meta-analysis

BACKGROUND

Clinical scores for sepsis have been primarily developed for, and applied in High-Income Countries. This systematic review and meta-analysis examined the performance of the quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS), Modified Early Warning Score (MEWS), and Universal Vital Assessment (UVA) scores for diagnosis and prediction of mortality in patients with suspected infection in Low-and-Middle-Income Countries.

METHODS

PubMed, Science Direct, Web of Science, and the Cochrane Central Register of Controlled Trials databases were searched until May 18, 2021. Studies reporting the performance of at least one of the above-mentioned scores for predicting mortality in patients of 15 years of age and older with suspected infection or sepsis were eligible. The Quality Assessment of Diagnostic Accuracy Studies tool was used for risk-of-bias assessment. PRISMA guidelines were followed (PROSPERO registration: CRD42020153906). The bivariate random-effects regression model was used to pool the individual sensitivities, specificities and areas-under-the-curve (AUC).

FINDINGS

Twenty-four articles (of 5669 identified) with 27,237 patients were eligible for inclusion. qSOFA pooled sensitivity was 0·70 (95% confidence interval [CI] 0·60-0·78), specificity 0·73 (95% CI 0·67-0·79), and AUC 0·77 (95% CI 0·72-0·82). SIRS pooled sensitivity, specificity and AUC were 0·88 (95% CI 0·79 -0·93), 0·34 (95% CI 0·25-0·44), and 0·69 (95% CI 0·50-0·83), respectively. MEWS pooled sensitivity, specificity and AUC were 0·70 (95% CI 0·57 -0·81), 0·61 (95% CI 0·42-0·77), and 0·72 (95% CI 0·64-0·77), respectively. UVA pooled sensitivity, specificity and AUC were 0·49 (95% CI 0·33 -0·65), 0·91(95% CI 0·84-0·96), and 0·76 (95% CI 0·44-0·93), respectively. Significant heterogeneity was observed in the pooled analysis.

INTERPRETATION

Individual score performances ranged from poor to acceptable. Future studies should combine selected or modified elements of different scores.

FUNDING

Partially funded by the UK National Institute for Health Research (NIHR) (17/63/42).