Risk stratification of severe sepsis patients in the emergency department

Reverse Engineering of the Pediatric Sepsis Regulatory Network and Identification of Master Regulators

Sepsis remains a leading cause of death in ICUs all over the world, with pediatric sepsis accounting for a high percentage of mortality in pediatric ICUs. Its complexity makes it difficult to establish a consensus on genetic biomarkers and therapeutic targets. A promising strategy is to investigate the regulatory mechanisms involved in sepsis progression, but there are few studies regarding gene regulation in sepsis. This work aimed to reconstruct the sepsis regulatory network and identify transcription factors (TFs) driving transcriptional states, which we refer to here as master regulators. We used public gene expression datasets to infer the co-expression network associated with sepsis in a retrospective study. We identified a set of 15 TFs as potential master regulators of pediatric sepsis, which were divided into two main clusters. The first cluster corresponded to TFs with decreased activity in pediatric sepsis, and GATA3 and RORA, as well as other TFs previously implicated in the context of inflammatory response. The second cluster corresponded to TFs with increased activity in pediatric sepsis and was composed of TRIM25, RFX2, and MEF2A, genes not previously described as acting in a coordinated way in pediatric sepsis. Altogether, these results show how a subset of master regulators TF can drive pathological transcriptional states, with implications for sepsis biology and treatment.

In-hospital mortality associated factors in elderly patients with invasive mechanical ventilation in the emergency department

AIMS

To identify factors associated with in-hospital mortality, to estimate the intubation rate and to describe in-hospital mortality in patients over 65 years old with invasive mechanical ventilation (IMV) in the emergency department (ED).

METHODS

Retrospective cohort study of patients over 65 years old, who were intubated in an ED of a high complexity hospital between 2016 and 2018. Demographic data, comorbidities, and severity scores on admission were described. Bivariate and multivariate analyses were performed with logistic regression according to mortality and possible confounders.

RESULTS

A total of 285 patients with a mean age of 80 years required IMV in the emergency department, for a median of 3 days, and with a mean APACHE II score of 20 points of severity. The IMV rate was .48% (95% CI .43-.54), and 55.44% (158) died. Mortality-associated factors after age and sex adjustment were stroke (OR 2.13; 95% CI 1.21-3.76), chronic kidney failure, (OR 4.,38; 95% CI 1.91-10.04), Charlson index (OR 1.19; 95% CI 1.02-1.38), APACHE II score (OR 1.07; 95% CI 1.02-1.12), and SOFA score (OR 1.14; 95% CI 1.03-1.27).

DISCUSSION

Our IMV rate was lower than that stated by Johnson et al. in the United States in 2018 (.59%). In-hospital mortality in our study exceeded that predicted by the APACHE II score (40%) and SOFA (33%). However it was consistent with that reported by Lieberman et al. in Israel and Esteban et al. in the United States.

CONCLUSIONS

Although the IMV rate was low in the ED, more than half the patients died during hospitalization. Pre-existing cerebrovascular and renal diseases and high results in the comorbidities index and severity scores on admission were independent factors associated with in-hospital mortality.

Lactate-enhanced-qSOFA (LqSOFA) score is superior to the other four rapid scoring tools in predicting in-hospital mortality rate of the sepsis patients

Background

The rising prevalence of early therapy for sepsis has led to the demand for rapid risk-stratification tools that can estimate the risk of in-hospital mortality for sepsis patients and the need for intensive care unit (ICU) admission. A robust risk-stratification tool is crucial for in-time sepsis treatment. This study aimed to compare the abilities of five rapid scoring systems, i.e., LqSOFA score, qSOFA score, SIRS, MEDS, and MEWS, in predicting the mortality in hospital and ICU admission for sepsis patients.

Methods

A retrospective observational clinical study was conducted in West China Hospital. Our cases included all patients admitted to the hospital with a diagnosis of sepsis (sepsis-3). We calculated five rapid prediction scores for the enrolled cases. We then compared each rapid score’s ability to predict in-hospital mortality and ICU admission.

Results

A total of 821 of mixed sepsis patients by sepsis-3 definition were included. The all-cause hospital mortality rate was 21.1%. The LqSOFA score presented the most significant discrimination with an area under the receiver operating characteristic curve (AUC) of 0.751. The AUC of the LqSOFA score for mortality in the hospital was significantly higher than qSOFA (AUC 0.717), SIRS (AUC 0.704), MEDS (AUC 0.670), and MEWS (AUC 0.685).

Conclusions

LqSOFA is a superior prognostic tool for predicting mortality in the hospital. It may provide more exact information for hospital mortality than the other 4 rapid scores in treating sepsis patients.

Prognostic utilization of models based on the APACHE II, APACHE IV, and SAPS II scores for predicting in-hospital mortality in emergency department

BACKGROUND

This study was designed to evaluate and compare the prognostic value of the APACHE II, APACHE IV, and SAPSII scores for predicting in-hospital mortality in the ED on a large sample of patients. Earlier studies in the ED setting have either used a small sample or focused on specific diagnoses.

METHODS

A prospective study was conducted to include patients with higher risk of mortality from March 2016 to March 2017 in the ED of Emam Reza Hospital, northeast of Iran. Logistic regression was used to develop three models. Evaluation was performed in terms of the overall performance (Brier Score, BS, and Brier Skill Score, BSS), discrimination (Area Under the Curve, AUC), and calibration (calibration graph).

RESULTS

A total of 2205 patients met the study criteria (53% male and median age of 64, IQR: 50-77). In-hospital mortality amounted to 19%. For APACHE II, APACHE IV, and SAPS II the BS was 0.132, 0.125 and 0.133 and the BSS was 0.156, 0.2, and 0.144, respectively. The AUC was 0.755 (0.74 to 0.779) for APACHE II, 0.794 (0.775 to 0.818) for APACHE IV, and 0.751 (0.727 to 0.776) for SAPS II. The APACHE IV showed significantly greater AUC in comparison to the APACHE II and SAPS II. The graphical evaluation revealed good calibration of the APACHE IV model.

CONCLUSION

APACHEIV outperformed APACHEII and SAPSII in terms of discrimination and calibration. More validation is needed for using these models for decision-making about individual patients, although they would perform best at a cohort level.

Performance of the MEDS score in predicting mortality among emergency department patients with a suspected infection: a meta-analysis

OBJECTIVES

To carry out a meta-analysis to examine the prognostic performance of the Mortality in Emergency Department Sepsis (MEDS) score in predicting mortality among emergency department patients with a suspected infection.

METHODS

Electronic databases-PubMed, Embase, Scopus, EBSCO and the Cochrane Library-were searched for eligible articles from their respective inception through February 2019. Sensitivity, specificity, likelihood ratios and receiver operator characteristic area under the curve were calculated. Subgroup analyses were performed to explore the prognostic performance of MEDS in selected populations.

RESULTS

We identified 24 studies involving 21 246 participants. The pooled sensitivity of MEDS to predict mortality was 79% (95% CI 72% to 84%); specificity was 74% (95% CI 68% to 80%); positive likelihood ratio 3.07 (95% CI 2.47 to 3.82); negative likelihood ratio 0.29 (95% CI 0.22 to 0.37) and area under the curve 0.83 (95% CI 0.80 to 0.86). Significant heterogeneity was seen among included studies. Meta-regression analyses showed that the time at which the MEDS score was measured and the cut-off value used were important sources of heterogeneity.

CONCLUSION

The MEDS score has moderate accuracy in predicting mortality among emergency department patients with a suspected infection. A study comparison MEDS and qSOFA in the same population is needed.

Incidence, trends, and outcomes of infection sites among hospitalizations of sepsis: A nationwide study

Purpose

To determine the trends of infection sites and outcome of sepsis using a national population-based database.

Materials and methods

Using the Nationwide Inpatient Sample database of the US, adult sepsis hospitalizations and infection sites were identified using a validated approach that selects admissions with explicit ICD-9-CM codes for sepsis and diagnosis/procedure codes for acute organ dysfunctions. The primary outcome was the trend of incidence and in-hospital mortality of specific infection sites in sepsis patients. The secondary outcome was the impact of specific infection sites on in-hospital mortality.

Results

During the 9-year period, we identified 7,860,687 admissions of adult sepsis. Genitourinary tract infection (36.7%), lower respiratory tract infection (36.6%), and systemic fungal infection (9.2%) were the leading three sites of infection in patients with sepsis. Intra-abdominal infection (30.7%), lower respiratory tract infection (27.7%), and biliary tract infection (25.5%) were associated with highest mortality rate. The incidences of all sites of infections were trending upward. Musculoskeletal infection (annual increase: 34.2%) and skin and skin structure infection (annual increase: 23.0%) had the steepest increase. Mortality from all sites of infection has decreased significantly (trend p<0.001). Skin and skin structure infection had the fastest declining rate (annual decrease: 5.5%) followed by primary bacteremia (annual decrease: 5.3%) and catheter related bloodstream infection (annual decrease: 4.8%).

Conclusions

The anatomic site of infection does have a differential impact on the mortality of septic patients. Intra-abdominal infection, lower respiratory tract infection, and biliary tract infection are associated with higher mortality in septic patients.

Performance Assessment of the Mortality in Emergency Department Sepsis Score, Modified Early Warning Score, Rapid Emergency Medicine Score, and Rapid Acute Physiology Score in Predicting Survival Outcomes of Adult Renal Abscess Patients in the Emergency Department

Background

Renal abscess is a relatively uncommon yet debilitating and potentially fatal disease. There is no clearly defined, objective risk stratification tool available for emergency physicians' and surgeons' use in the emergency department (ED) to quickly determine the appropriate management strategy for these patients, despite early intervention having a beneficial impact on survival outcomes.

Objective

This case control study evaluates the performance of Mortality in Emergency Department Sepsis Score (MEDS), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting risk of mortality in ED adult patients with renal abscess. This will help emergency physicians, surgeons, and intensivists expedite the time-sensitive decision-making process.

Methods

Data from 152 adult patients admitted to the EDs of two training and research hospitals who had undergone a contrast-enhanced computed tomography scan of the abdomen and was diagnosed with renal abscess from January 2011 to December 2015 were analyzed, with the corresponding MEDS, MEWS, REMS, RAPS, and mortality risks calculated. Ability to predict patient mortality was assessed via receiver operating curve analysis and calibration analysis.

Results

MEDS was found to be the best performing physiologic scoring system, with sensitivity, specificity, and accuracy of 87.50%, 88.89%, and 88.82%, respectively. Area under receiver operating characteristic curve (AUROC) value was 0.9440, and negative predictive value was 99.22% with a cutoff of 9 points.

Conclusion

Our study is the largest of its kind in examining ED patients with renal abscess. MEDS has been demonstrated to be superior to MEWS, REMS, and RAPS in predicting mortality for this patient population. We recommend its use for evaluation of disease severity and risk stratification in these patients, to expedite identification of critically ill patients requiring urgent intervention.

A novel heart rate variability based risk prediction model for septic patients presenting to the emergency department

A quick, objective, non-invasive means of identifying high-risk septic patients in the emergency department (ED) can improve hospital outcomes through early, appropriate management. Heart rate variability (HRV) analysis has been correlated with mortality in critically ill patients. We aimed to develop a Singapore ED sepsis (SEDS) predictive model to assess the risk of 30-day in-hospital mortality in septic patients presenting to the ED. We used demographics, vital signs, and HRV parameters in model building and compared it with the modified early warning score (MEWS), national early warning score (NEWS), and quick sequential organ failure assessment (qSOFA) score.Adult patients clinically suspected to have sepsis in the ED and who met the systemic inflammatory response syndrome (SIRS) criteria were included. Routine triage electrocardiogram segments were used to obtain HRV variables. The primary endpoint was 30-day in-hospital mortality. Multivariate logistic regression was used to derive the SEDS model. MEWS, NEWS, and qSOFA (initial and worst measurements) scores were computed. Receiver operating characteristic (ROC) analysis was used to evaluate their predictive performances.Of the 214 patients included in this study, 40 (18.7%) met the primary endpoint. The SEDS model comprises of 5 components (age, respiratory rate, systolic blood pressure, mean RR interval, and detrended fluctuation analysis α2) and performed with an area under the ROC curve (AUC) of 0.78 (95% confidence interval [CI]: 0.72-0.86), compared with 0.65 (95% CI: 0.56-0.74), 0.70 (95% CI: 0.61-0.79), 0.70 (95% CI: 0.62-0.79), 0.56 (95% CI: 0.46-0.66) by qSOFA (initial), qSOFA (worst), NEWS, and MEWS, respectively.HRV analysis is a useful component in mortality risk prediction for septic patients presenting to the ED.

The SPEED (sepsis patient evaluation in the emergency department) score: a risk stratification and outcome prediction tool

Objectives

The aim of the study was to identify covariates associated with 28-day mortality in septic patients admitted to the emergency department and derive and validate a score that stratifies mortality risk utilizing parameters that are readily available.

Methods

Patients with an admission diagnosis of suspected or confirmed infection and fulfilling at least two criteria for severe inflammatory response syndrome were included in this study. Patients’ characteristics, vital signs, and laboratory values were used to identify prognostic factors for mortality. A scoring system was derived and validated. The primary outcome was the 28-day mortality rate.

Results

A total of 440 patients were included in the study. The 28-day hospital mortality rate was 32.4 and 25.2% for the derivation (293 patients) and validation (147 patients) sets, respectively. Factors associated with a higher mortality were immune-suppressed state (odds ratio 4.7; 95% confidence interval 2.0–11.4), systolic blood pressure on arrival less than 90 mmHg (3.8; 1.7–8.3), body temperature less than 36.0°C (4.1; 1.3–12.9), oxygen saturation less than 90% (2.3; 1.1–4.8), hematocrit less than 0.38 (3.1; 1.6–5.9), blood pH less than 7.35 (2.0; 1.04–3.9), lactate level more than 2.4 mmol/l (2.27; 1.2–4.2), and pneumonia as the source of infection (2.7; 1.5–5.0). The area under the receiver operating characteristic curve was 0.81 (0.75–0.86) in the derivation and 0.81 (0.73–0.90) in the validation set. The SPEED (sepsis patient evaluation in the emergency department) score performed better (P=0.02) than the Mortality in Emergency Department Sepsis score when applied to the complete study population with an area under the curve of 0.81 (0.76–0.85) as compared with 0.74 (0.70–0.79).

Conclusion

The SPEED score predicts 28-day mortality in septic patients. It is simple and its predictive value is comparable to that of other scoring systems.

Comparison of the Mortality in Emergency Department Sepsis Score, Modified Early Warning Score, Rapid Emergency Medicine Score and Rapid Acute Physiology Score for predicting the outcomes of adult splenic abscess patients in the emergency department

Background

Splenic abscess is rare but has mortality rates as high as 14% even with recent improvements in management. Early and appropriate intervention may improve patient outcomes, yet at present there is no identified method that can predict mortality risk rapidly and accurately for emergency physicians, surgeons, and intensivists to decide on the ideal course of action.

Objective

This study aims to evaluate the performance of Mortality in Emergency Department Sepsis Score (MEDS), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS) and Rapid Acute Physiology Score (RAPS) for predicting the mortality risk of adult splenic abscess patients. This will expedite decision making in the emergency department (ED) to increase survival rates and help avoid unnecessary splenectomies.

Methods

Data of 114 adult patients admitted to the EDs of 4 research and training hospitals who had undergone an abdominal contrast CT scan and diagnosed with splenic abscess between Jan 2000 and April 2015 were analyzed. The MEDS, MEWS, REMS, and RAPS and their corresponding mortality risks were calculated, with their abilities to predict patient mortality assessed through receiver operating characteristic curve analysis and calibration analysis.

Results

MEDS was found to be the best performing scoring system across all indicators, with sensitivity, specificity, and accuracy of 92.86%, 88.00%, and 88.60% respectively; its area under curve for AUROC analysis was 0.92. With a cutoff value of 8, negative predictive value of MEDS was 98.88%.

Conclusion

Our series is the largest multicenter study in adult ED patients with splenic abscess. The results from the present study show that MEDS is superior to MEWS, REMS and RAPS in predicting mortality, thus allowing earlier detection of critically ill adult ED splenic abscess patients. Therefore, we recommend that MEDS be used for predicting severity of illness and risk stratification in these patients.

Are prognostic scores and biomarkers such as procalcitonin the appropriate prognostic precursors for elderly patients with sepsis in the emergency department?

BACKGROUND

The mortality of patients with severe sepsis and septic shock is still high, and the prognosis of elderly patients tends to be particularly poor. Therefore, this study sought to conduct a comparative analysis of the abbreviated mortality in emergency department sepsis (abbMEDS) score, sequential organ failure assessment (SOFA) score, infection probability score (IPS), initial procalcitonin (PCT), and cytokine levels to investigate the effectiveness of each index in predicting the prognosis of elderly patients with sepsis in the emergency department (ED).

METHODS

This was a single-center prospective study, and classified 55 patients (≥65 years of age) with systemic inflammatory response syndrome (SIRS) from January 2013 to December 2013 in the ED. A total of 36 elderly patients were diagnosed with sepsis. The prediction of prognosis using the prognostic scores (abbMEDS, SOFA, IPS) was analyzed. An early blood examination (WBC count, C-reactive protein, PCT, and cytokines) was conducted within the first 2 h of the patient's arrival at the ED.

RESULTS

The median (IQR) age of subjects was 76.5 (70.5-81.5). After 28 days, 27 subjects (75 %) had survived, and 9 (25 %) had died. Fifteen (41.7 %) were sent to intensive care units (ICUs). The SOFA score and abbMEDS showed higher median (IQR) values of 9.5 (7.0-11.0) and 13.5 (12.0-15.0), respectively, in the ICU group than in the general ward group (p < 0.001). Analysis of the levels of PCT, IL-10, IL-6, and IL-5 had a significantly better ability to predict ICU admission (p = 0.001, p = 0.023, p = 0.030, p = 0.001). The prediction of mortality in the first 28 days via SOFA and the abbMEDS resulted in scores of 11.0 (8.0-11.0) and 14.0 (12.5-15.5) (p = 0.004, p = 0.003), respectively. However, levels of IPS, PCT, and cytokines did not show significant differences.

CONCLUSIONS

In predicting ICU admission and the death of elderly sepsis patients in ED, SOFA and abbMEDS scores were effective. Of the various biomarkers, PCT, IL-10, IL-6, and IL-5 were effective in predicting ICU admission, but were not effective in predicting the death of elderly sepsis patients.

Prognostic value of PCT in septic emergency patients

Background

An accurate assessment of septic patients at risk for poor clinical outcomes is challenging for clinicians in the emergency department (ED).

Objectives

We aimed to evaluate the prognostic value of procalcitonin (PCT) in septic patients in the ED for predicting death.

Results

In a retrospective study, 188 septic patients (median age 63 [IQR 51–80]) of two French university hospitals were included. Patients who deceased within 30 days (20 %, n = 37) presented higher PCT value at admission (median 34.0 µg/L [5.0–71.9]) in comparison with the survivals (median 6.4 µg/L [4.1–13.1], p = 0.0005). ROC curve analysis indicated a moderate AUC of 0.686 [95 % CI 0.613–0.752] and an optimal PCT threshold value at 32.5 [95 % CI 21.8–43.3] µg/L that was associated with a 51 % [34–67] sensitivity, a 96 % [90–98] specificity, a 73 % [52–88] positive predictive value, and a 89 % [83–93] negative predictive value for death. Only 26 patients (14 %) had PCT values above this threshold (19 in the deceased group vs 7 in survival group, p < 0.0001). By multivariate analysis, only three variables remained significantly predictive of the death: personal history of cardiovascular disease (OR 3.1 [1.0–9.4], p = 0.046), the presence of severe sepsis/septic shock in the ER (OR 4.4 [1.3–12.3], p = 0.013), and a PCT level >32.5 µg/L (OR 36.0 [10.0–128.4], p < 0.0001). Similar results were obtained when considering the combined outcome death and/or admission in ICU.

Conclusion

Elevated value of PCT at admission has moderate accuracy to identify poor outcome in ED septic patients in daily practice.

Usefulness of the Mortality in Severe Sepsis in the Emergency Department score in an urban tertiary care hospital

BACKGROUND

The Mortality in Severe Sepsis in the Emergency Department (MISSED) score is a newly proposed scoring system. The goal of this study is to determine if the MISSED score is generalizable to an urban tertiary care hospital.

METHODS

This is a retrospective chart review conducted from July 2012 to June 2014. Inclusion criteria consisted of adult emergency department (ED) patients with severe sepsis, defined as lactate level 4mmol/L or greater. Demographics, lactate, international normalized ratio (INR), albumin, intensive care unit admission, and ED intubation were analyzed using χ(2) test, t test, and logistic regression. The MISSED score was calculated using the variables albumin 27g/L or less, INR 1.3 or greater, and age 65years or older and analyzed using the area under the curve. The primary outcome was inhospital mortality.

RESULTS

A total of 182 patients met inclusion criteria, and mortality was 32%. Patients in the mortality group had older age (58.1±17.2 vs 62.7±14.7; P=.07), higher lactate (5.9±2.7 vs 7.3±3.1; P<.01), lower albumin (34.3±8.3 vs 25.6±7.1; P<.0001), higher INR (1.4±0.6 vs 2.4±1.9; P<.0001), ED intubation (21% vs 56%; P<.0001), and intensive care unit admission (41% vs 78%; P<.0001). The regression model found that albumin of 27g/L or less (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.05-3.36), INR 1.3 or greater (OR, 8.3; 95% CI, 3.35-20.51), and ED intubation (OR, 5.6; 95% CI, 2.56-12.35) predicted mortality. The area under the curve for the MISSED score was 0.78 (95% CI, 0.73-0.85).

CONCLUSION

The MISSED score is useful for predicting mortality in ED patients with severe sepsis.

Value of plasma neutrophil gelatinase-associated lipocalin in predicting the mortality of patients with sepsis at the emergency department

BACKGROUND

Sepsis is a major cause of morbidity and mortality in the emergency department. This study aimed to evaluate the assessment of severity of sepsis by and prognostic value of plasma neutrophil gelatinase-associated lipocalin (NGAL) compared with other widely used biological markers of inflammation in patients with sepsis.

METHODS

NGAL, procalcitonin, and C-reactive protein values were measured in 470 patients with suspected sepsis, and the Mortality in Emergency Department Sepsis (MEDS) score was obtained for all enrolled subjects, who were followed for up to 28days.

RESULTS

The median plasma NGAL value was increased with sepsis severity according to the MEDS score. The plasma NGAL value was higher in nonsurvivors than in survivors. The area under the receiver operating characteristic curve of NGAL (0.797) was greater than that of procalcitonin (0.599) and MEDS score (0.774) in predicting 28-day hospital mortality. Multivariable logistic regression found that the plasma NGAL value was an independent predictor for hospital mortality in patients with sepsis. The plasma NGAL values were positively correlated with C-reactive protein and procalcitonin levels, and MEDS scores.

CONCLUSIONS

Plasma NGAL is a valuable biological marker in the assessment of severity and prediction of prognosis of patients with sepsis in the emergency department.

Comparison of PIRO, SOFA, and MEDS scores for predicting mortality in emergency department patients with severe sepsis and septic shock

OBJECTIVES

The Predisposition Insult Response and Organ failure (PIRO) scoring system has been developed for use in the emergency department (ED) to risk stratify sepsis cases, but has not been well studied among high-risk patients with severe sepsis and septic shock. The PIRO score was compared with the Sequential Organ Failure Assessment (SOFA) and Mortality in ED Sepsis (MEDS) scores to predict mortality in ED patients with features suggesting severe sepsis or septic shock in the ED.

METHODS

This was an analysis of sepsis patients enrolled in a prospective observational ED study of patients presenting with evidence of shock, hypoxemia, or other organ failure. PIRO, MEDS, and SOFA scores were calculated from ED data. Analysis compared areas under the receiver operator characteristic (ROC) curves for 30-day mortality.

RESULTS

Of 240 enrolled patients, final diagnoses were septic shock in 128 (53%), severe sepsis without shock in 70 (29%), and infection with no organ dysfunction in 42 (18%). Forty-eight (20%) patients died within 30 days of presentation. Area under the ROC curve (AUC) for mortality was 0.86 (95% confidence interval [CI] = 0.80 to 0.92) for PIRO, 0.81 (95% CI = 0.74 to 0.88) for MEDS, and 0.78 (95% CI = 0.71 to 0.87) for SOFA scores. Pairwise comparisons of the AUC were as follows: PIRO versus SOFA, p = 0.01; PIRO versus MEDS, p = 0.064; and MEDS versus SOFA; p = 0.37. Mortality increased with increasing PIRO scores: PIRO < 5, 0%; PIRO 5 to 9, 5%; PIRO 10 to 14, 5%; PIRO 15 to 19, 37%; and PIRO ≥ 20, 80% (p < 0.001). The MEDS score also showed increasing mortality with higher scores: MEDS < 5, 0%; MEDS 5 to 7, 12%; MEDS 8 to 11, 15%; MEDS 12 to 14, 48%; and MEDS > 15, 65% (p < 0.001).

CONCLUSIONS

The PIRO model, taking into account comorbidities and septic source as well as physiologic status, performed better than the SOFA score and similarly to the MEDS score for predicting mortality in ED patients with severe sepsis and septic shock. These findings have implications for identifying and managing high-risk patients and for the design of clinical trials in sepsis.

Intensive care unit scoring systems outperform emergency department scoring systems for mortality prediction in critically ill patients: a prospective cohort study

BACKGROUND

Multiple scoring systems have been developed for both the intensive care unit (ICU) and the emergency department (ED) to risk stratify patients and predict mortality. However, it remains unclear whether the additional data needed to compute ICU scores improves mortality prediction for critically ill patients compared to the simpler ED scores.

METHODS

We studied a prospective observational cohort of 227 critically ill patients admitted to the ICU directly from the ED at an academic, tertiary care medical center. We compared Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Simplified Acute Physiology Score (SAPS) II, Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), Prince of Wales Emergency Department Score (PEDS), and a pre-hospital critical illness prediction score developed by Seymour et al. (JAMA 2010, 304(7):747-754). The primary endpoint was 60-day mortality. We compared the receiver operating characteristic (ROC) curves of the different scores and their calibration using the Hosmer-Lemeshow goodness-of-fit test and visual assessment.

RESULTS

The ICU scores outperformed the ED scores with higher area under the curve (AUC) values (p = 0.01). There were no differences in discrimination among the ED-based scoring systems (AUC 0.698 to 0.742; p = 0.45) or among the ICU-based scoring systems (AUC 0.779 to 0.799; p = 0.60). With the exception of the Seymour score, the ED-based scoring systems did not discriminate as well as the best-performing ICU-based scoring system, APACHE III (p = 0.005 to 0.01 for comparison of ED scores to APACHE III). The Seymour score had a superior AUC to other ED scores and, despite a lower AUC than all the ICU scores, was not significantly different than APACHE III (p = 0.09). When data from the first 24 h in the ICU was used to calculate the ED scores, the AUC for the ED scores improved numerically, but this improvement was not statistically significant. All scores had acceptable calibration.

CONCLUSIONS

In contrast to prior studies of patients based in the emergency department, ICU scores outperformed ED scores in critically ill patients admitted from the emergency department. This difference in performance seemed to be primarily due to the complexity of the scores rather than the time window from which the data was derived.

Comparison of risk prediction scoring systems for ward patients: a retrospective nested case-control study

INTRODUCTION

The rising prevalence of rapid response teams has led to a demand for risk-stratification tools that can estimate a ward patient's risk of clinical deterioration and subsequent need for intensive care unit (ICU) admission. Finding such a risk-stratification tool is crucial for maximizing the utility of rapid response teams. This study compares the ability of nine risk prediction scores in detecting clinical deterioration among non-ICU ward patients. We also measured each score serially to characterize how these scores changed with time.

METHODS

In a retrospective nested case-control study, we calculated nine well-validated prediction scores for 328 cases and 328 matched controls. Our cohort included non-ICU ward patients admitted to the hospital with a diagnosis of infection, and cases were patients in this cohort who experienced clinical deterioration, defined as requiring a critical care consult, ICU admission, or death. We then compared each prediction score's ability, over the course of 72 hours, to discriminate between cases and controls.

RESULTS

At 0 to 12 hours before clinical deterioration, seven of the nine scores performed with acceptable discrimination: Sequential Organ Failure Assessment (SOFA) score area under the curve of 0.78, Predisposition/Infection/Response/Organ Dysfunction Score of 0.76, VitalPac Early Warning Score of 0.75, Simple Clinical Score of 0.74, Mortality in Emergency Department Sepsis of 0.74, Modified Early Warning Score of 0.73, Simplified Acute Physiology Score II of 0.73, Acute Physiology and Chronic Health Evaluation II of 0.72, and Rapid Emergency Medicine Score of 0.67. By measuring scores over time, it was found that average SOFA scores of cases increased as early as 24 to 48 hours prior to deterioration (P = 0.01). Finally, a clinical prediction rule which also accounted for the change in SOFA score was constructed and found to perform with a sensitivity of 75% and a specificity of 72%, and this performance is better than that of any SOFA scoring model based on a single set of physiologic variables.

CONCLUSIONS

ICU- and emergency room-based prediction scores can also be used to prognosticate risk of clinical deterioration for non-ICU ward patients. In addition, scoring models that take advantage of a score's change over time may have increased prognostic value over models that use only a single set of physiologic measurements.

[Validation of APACHE II and SOFA scores in 2 cohorts of patients with suspected infection and sepsis, not admitted to critical care units]

OBJECTIVE

To validate the APACHE II and SOFA scores in patients with suspected infection in clinical settings other than intensive care units.

MATERIALS AND METHODS

A secondary analysis was performed on 2,530 adult patients participating in 2 cohort studies, with suspected infection as admission diagnosis within the first 24 h of hospitalization. The performance of both scoring systems was studied in order to set calibration and discrimination, respectively, on the outcomes such as mortality, admission to Intensive Care Unit, development of septic shock, or multiple organ dysfunctions.

RESULTS

The AUC-ROC values for mortality at discharge and on day 28 in the first cohort were around 0.50 for the SOFA and APACHE II scores; whereas for the second cohort the discrimination value was around 0.70. Calibration of both scoring systems for primary outcomes, according to Hosmer-Lemeshow test, showed p>.05 in the first cohort; while in the second cohort calibration it only showed a p>.05 in the case of the SOFA for mortality at hospital discharge.

CONCLUSION

This validation study of SOFA and APACHE II scores in patients with suspected infection in-hospital units other than the Intensive Care Unit, showed no consistent performance for calibration and discrimination. Its application in emergency and in-hospital patients is limited.

Comparison of risks factors for unplanned ICU transfer after ED admission in patients with infections and those without infections

Background. The objectives of this study were to compare the risk factors for unplanned intensive care unit (ICU) transfer after emergency department (ED) admission in patients with infections and those without infections and to explore the feasibility of using risk stratification tools for sepsis to derive a prediction system for such unplanned transfer. Methods. The ICU transfer group included 313 patients, while the control group included 736 patients randomly selected from those who were not transferred to the ICU. Candidate variables were analyzed for association with unplanned ICU transfer in the 1049 study patients. Results. Twenty-four variables were associated with unplanned ICU transfer. Sixteen (66.7%) of these variables displayed association in patients with infections and those without infections. These common risk factors included specific comorbidities, physiological responses, organ dysfunctions, and other serious symptoms and signs. Several common risk factors were statistically independent. Conclusions. The risk factors for unplanned ICU transfer in patients with infections were comparable to those in patients without infections. The risk factors for unplanned ICU transfer included variables from multiple dimensions that could be organized according to the PIRO (predisposition, insult/infection, physiological response, and organ dysfunction) model, providing the basis for the development of a predictive system.

Is comorbid status the best predictor of one-year mortality in patients with severe sepsis and sepsis with shock?

Understanding longer term outcomes in critically ill patients will assist treatment decisions, allocation of scarce resources and clinical research in that population. The aim of this study was to compare a well-validated means of determining comorbidity, the Charlson Comorbidity Score, to other verified risk stratification models in predicting one-year mortality and other outcomes in emergency department patients with severe sepsis and sepsis with shock. We conducted a planned subgroup analysis of a prospective observational study, the Critical Illness and Shock Study, in adult patients with sepsis meeting study criteria for critical illness. From emergency department arrival, patients were prospectively enrolled with data collected for a minimum of one year post-enrolment. Scoring systems were derived from this data and compared using receiver-operating characteristic curves. One hundred and four patients were enrolled. The 28-day mortality was 18% and one-year mortality 40%. For predicting one-year mortality, the area under the receiver-operating characteristic curve for age-weighted Charlson Comorbidity Score (0.71, 95% confidence interval 0.61 to 0.81) was at least as good or superior to other scoring systems analysed. The intensive care unit admission rate was 45% and the median hospital length-of-stay was eight days. We conclude that in patients who present to the emergency department with severe sepsis or sepsis with shock, age-weighted Charlson Comorbidity Score is a predictor of one-year mortality that is simple to calculate and at least as accurate as other validated scoring systems.

The Mortality in Emergency Department Sepsis Score as a Predictor of 1-Month Mortality among Adult Patients with Sepsis: Weighing the Evidence

Objective. To evaluate the performance of Mortality in Emergency Department Sepsis (MEDS) score in comparison to biomarkers as a predictor of mortality in adult emergency department (ED) patients with sepsis. Methods. A literature search was performed using PubMed, ScienceDirect, SpringerLink, and Ovid databases. Studies were appraised by using the C2010 Consensus Process for Levels of Evidence for prognostic studies. The respective values for area under the curve (AUC) were obtained from the selected articles. Results. Four relevant articles met the selection process. Three studies defined the 1-month mortality as death occurring within 28 days of ED presentation, while the remaining one subcategorised the outcome measure as (5-day) early and (6- to 30-day) late mortality. In all four studies, the MEDS score performed better than the respective comparators (C-reactive protein, lactate, procalcitonin, and interleukin-6) in predicting mortality with an AUC ranging from 0.78 to 0.89 across the studies. Conclusion. The MEDS score has a better prognostic value than the respective comparators in predicting 1-month mortality in adult ED patients with suspected sepsis.

Paraplegia in a chiropractic patient secondary to atraumatic dural arteriovenous fistula with perimedullary hypertension: case report

Intracranial dural arteriovenous fistulas are abnormal communications between higher-pressure arterial circulation and lower-pressure venous circulation. This abnormal communication can result in important and frequently misdiagnosed neurological abnormalities.A case of rapid onset paraplegia following cervical chiropractic manipulation is reviewed. The patient's generalized spinal cord edema, lower extremity paraplegia and upper extremity weakness, were initially believed to be a complication of the cervical spinal manipulation that had occurred earlier on the day of admission. Subsequent diagnostic testing determined the patient suffered from impaired circulation of the cervical spinal cord produced by a Type V intracranial arteriovenous fistula and resultant venous hypertension in the pontomesencephalic and anterior spinal veins.The clinical and imaging findings of an intracranial dural arteriovenous fistula with pontomesencephalic venous congestion and paraplegia are reviewed.This case report emphasizes the importance of thorough and serial diagnostic imaging in the presence of sudden onset paraplegia and the potential for error when concluding atypical neurological presentations are the result of therapeutic misadventure.

Evaluation of the Mortality in Emergency Department Sepsis score combined with procalcitonin in septic patients

OBJECTIVE

To determine an effective method for predicting severity of sepsis and 28-day mortality of emergency department (ED) patients, we compared the Mortality in Emergency Department Sepsis (MEDS) score with procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) and evaluated the MEDS score combined with relevant biomarkers.

METHODS

A total of 501 adult ED patients with sepsis were selected for this prospective clinical study. The optimal combination was assessed by logistic regression. All cases were divided into the sepsis group (319 cases) and the severe sepsis and septic shock group (182 cases) according to the severity of sepsis, as well as the survivor group (367 cases) and nonsurvivor group (134 cases) according to the 28-day outcomes.

RESULTS

The area under the curve of the MEDS score, PCT, IL-6, and CRP was 0.793, 0.712, 0.695, and 0.681 for severity of sepsis and 0.776, 0.681, 0.692, and 0.661 for 28-day mortality, respectively. Only PCT was an independent predictor when combined with the MEDS score. The new combination of the MEDS score with PCT improved the area under the curve for severity (0.852) and mortality (0.813). This new combination for evaluation of severity had better sensitivity (63.2%), specificity (92.2%), and positive predictive (82.1%) and negative predictive (81.4%) values.

CONCLUSIONS

The predictive ability of the MEDS score for severity and 28-day mortality of septic ED patients is better than PCT, IL-6, and CRP levels. The MEDS score combined with PCT enhances the ability of risk stratification and prognostic evaluation.

Outcome predictors of uncomplicated sepsis

Background

The development of sepsis risk prediction models and treatment guidelines has largely been based on patients presenting in the emergency department (ED) with severe sepsis or septic shock. Therefore, in this study we investigated which patient characteristics might identify patients with an adverse outcome in a heterogeneous group of patients presenting with uncomplicated sepsis to the emergency department (ED).

Findings

We performed a retrospective cohort analysis of all ED patients presenting with uncomplicated sepsis in a large teaching hospital during a 3-month period. During this period, 70 patients fulfilled the criteria of uncomplicated sepsis. Eight died in the hospital. Non-survivors were characterized by a higher abbreviated Mortality in Emergency Department Sepsis (MEDS) score (7.2 ± 3.4 vs. 4.8 ± 2.9, p = 0.03) and a lower Hb (6.6 ± 1.2 vs. 7.7 ± 1.4, p = 0.03), and they used beta-blockers more often (75% vs. 19%, p < 0.01).

Conclusions

Non-survivors of uncomplicated sepsis had on average a higher abbreviated MEDS score, a lower hemoglobin (Hb) and more often used β-blockers compared to survivors. Early identification of these factors might contribute to optimization of sepsis treatment for this patient category and thereby prevent disease progression to severe sepsis or septic shock.

Evaluation of the modified MEDS, MEWS score and Charlson comorbidity index in patients with community acquired sepsis in the emergency department

Sepsis is one of the most important causes of morbidity and mortality in patients presenting to the emergency department. SIRS criteria that define sepsis are not specific and do not reflect the severity of infection. We aimed to evaluate the ability of the modified mortality in emergency department sepsis (MEDS) score, the modified early warning score (MEWS) and the Charlson comorbidity index (CCI) to predict prognosis in patients who are diagnosed in sepsis. We prospectively investigated the value of the CCI, MEWS and modified MEDS Score in the prediction of 28-day mortality in patients presenting to the emergency department who were diagnosed with sepsis. 230 patients were enrolled in the study. In these patients, the 5-day mortality was 17 % (n = 40) and the 28-day mortality was 32.2 % (n = 74). A significant difference was found between surviving patients and those who died in terms of their modified MEDS, MEWS and Charlson scores for both 5-day mortality (p < 0.001, p = 0.013 and p = 0.006, respectively) and 28-day mortality (p < 0.001, p = 0.008 and p < 0.001, respectively). The area under the curve (AUC) for the modified MEDS score in terms of 28-day mortality was 0.77. The MEDS score had a greater prognostic value compared to the MEWS and CCI scores. The performance of modified MEDS score was better than that of other scoring systems, in our study. Therefore, we believe that the modified MEDS score can be reliably used for the prediction of mortality in sepsis.

Outcome prediction using clinical scores and biomarkers in patients with presumed severe infection in the emergency department

BACKGROUND

Severe infections play an important role in the emergency department (ED) and early risk stratification is essential. We compared the prognostic value of APACHE II, SOFA, and MEDS scores, and the biomarkers C-reactive protein (CRP), procalcitonin (PCT), and interleukin 6 (IL-6).

METHODS

We performed a prospective observational study. Patients aged 18 years or older with a severe infection, from whom blood cultures were taken, were included.

RESULTS

Two hundred and eleven patients were included. The 30-day mortality rate was 8.5%. All scores and biomarkers showed significant area under the curve (AUC) values of receiver operating characteristic curve analysis for death within 30 days: 0.801 for APACHE II, 0.785 for MEDS, 0.708 for SOFA, 0.693 for CRP, 0.651 for PCT, and 0.716 for IL-6. For treatment in an ICU and need for mechanical ventilation, these parameters had significant AUC values, too. For renal replacement therapy, only APACHE II, SOFA, and PCT showed significant AUC values. According to the trend observed, the AUC values were highest for the APACHE II score.

CONCLUSIONS

All investigated parameters have a predictive value in patients with an infection in the ED. According to the trend observed, the APACHE II score seems to have the best discriminative power. Use of the APACHE II score already at the time of admission to the ED may be useful for stratifying patients at risk for ICU treatment, thereby using the same score in the ED and the ICU.

Comparison of severity of illness scoring systems in the prediction of hospital mortality in severe sepsis and septic shock

BACKGROUND

New scoring systems, including the Rapid Emergency Medicine Score (REMS), the Mortality in Emergency Department Sepsis (MEDS) score, and the confusion, urea nitrogen, respiratory rate, blood pressure, 65 years and older (CURB-65) score, have been developed for emergency department (ED) use in various patient populations. Increasing use of early goal directed therapy (EGDT) for the emergent treatment of sepsis introduces a growing population of patients in which the accuracy of these scoring systems has not been widely examined.

OBJECTIVES

To evaluate the ability of the REMS, MEDS score, and CURB-65 score to predict mortality in septic patients treated with modified EGDT.

MATERIALS AND METHODS

Secondary analysis of data from prospectively identified patients treated with modified EGDT in a large tertiary care suburban community hospital with over 85,000 ED visits annually and 700 inpatient beds, from May 2007 through May 2008. We included all patients with severe sepsis or septic shock, who were treated with our modified EGDT protocol. Our major outcome was in-hospital mortality. The performance of the scores was compared by area under the ROC curves (AUCs).

RESULTS

A total of 216 patients with severe sepsis or septic shock were treated with modified EGDT during the study period. Overall mortality was 32.9%. Calculated AUCs were 0.74 [95% confidence interval (CI): 0.67-0.81] for the MEDS score, 0.62 (95% CI: 0.54-0.69) for the REMS, and 0.59 (95% CI: 0.51-0.67) for the CURB-65 score.

CONCLUSION

We found that all three ED-based systems for scoring severity of illness had low to moderate predictive capability. The MEDS score demonstrated the largest AUC of the studied scoring systems for the outcome of mortality, although the CIs on point estimates of the AUC of the REMS and CURB-65 scores all overlap.

Peripheral photoplethysmography variability analysis of sepsis patients

Sepsis is associated with impairment in autonomic regulatory function. This work investigates the application of heart rate and photoplethysmogram (PPG) waveform variability analysis in differentiating two categories of sepsis, namely systemic inflammatory response syndrome (SIRS) and severe sepsis. Electrocardiogram-derived heart period (RRi) and PPG waveforms, measured from fingertips (Fin-PPG) and earlobes (Ear-PPG), of Emergency Department sepsis patients (n = 28) with different disease severity, were analysed by spectral technique, and were compared to control subjects (n = 10) in supine and 80° head-up tilted positions. Analysis of covariance (ANCOVA) was applied to adjust for the confounding factor of age. Low-frequency (LF, 0.04-0.15 Hz), mid-frequency (MF, 0.09-0.15 Hz) and high-frequency (HF, 0.15-0.60 Hz) powers were computed. The normalised MF power in Ear-PPG (MFnu(Ear)) was significantly reduced in severe sepsis patients with hyperlactataemia (lactate > 2 mmol/l), compared to SIRS patients (P < 0.05). Moreover, in a group of normal controls, MFnu(Ear) was not altered by head-up tilting (P > 0.05), suggesting that there may be a link between 0.1 Hz ear blood flow oscillation and tissue metabolic changes in sepsis, in addition to autonomic factors. The study highlighted the value of PPG spectral analysis in the non-invasive assessment of peripheral vascular regulation in sepsis patients, with potential implications in monitoring the progression of sepsis.

Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle

Physiologic scoring systems are often used to prognosticate mortality in critically ill patients. This study examined the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, Mortality in Emergency Department Sepsis (MEDS), and Mortality Probability Models (MPM) II0 in predicting in-hospital mortality of patients in the emergency department meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The discrimination and calibration characteristics of APACHE II, SAPS II, MEDS, and MPM II0 were evaluated. Data are presented as median and quartiles (25th, 75th). Two-hundred forty-six patients aged 68 (52, 81) years were analyzed from a prospectively maintained sepsis registry, with 76.0% of patients in septic shock, 45.5% blood culture positive, and 35.0% in-hospital mortality. Acute Physiology and Chronic Health Evaluation II, SAPS II, and MEDS scores were 29 (21, 37), 54 (40, 70), and 13 (11, 16), with predicted mortalities of 64% (40%, 85%), 58% (25%, 84%), and 16% (9%, 39%), respectively. Mortality Probability Models II0 showed a predicted mortality of 60% (27%, 80%). The area under the receiver operating characteristic curves was 0.73 for APACHE II, 0.71 for SAPS II, 0.60 for MEDS, and 0.72 for MPM II0. The standardized mortality ratios were 0.59, 0.63, 1.68, and 0.64, respectively. Thus, APACHE II, SAPS II, MEDS, and MPM II0 have variable abilities to discriminate early and estimate in-hospital mortality of patients presenting to the emergency department requiring the severe sepsis resuscitation bundle. Adoption of these prognostication tools in this setting may influence therapy and resource use for these patients.

Performance of the Mortality in Emergency Department Sepsis score for predicting hospital mortality among patients with severe sepsis and septic shock

OBJECTIVE

The aim of the study was to test if the Mortality in Emergency Department Sepsis (MEDS) score accurately predicts death among emergency department (ED) patients with severe sepsis and septic shock.

METHODS

This study was a preplanned secondary analysis of a before-and-after interventional study conducted at a large urban ED. Inclusion criteria were suspected infection, 2 or more criteria for systemic inflammation, and either systolic blood pressure of less than 90 mm Hg after a fluid bolus or lactate 4 mmol/L or higher. Exclusion criteria were: age of less than 18 years, no aggressive care desired, or need for immediate surgery. Clinical and outcomes data were prospectively collected on consecutive eligible patients for 1 year before and 1 year after implementing early goal-directed therapy (EGDT). The MEDS scores and probabilities of in-hospital death were calculated. The main outcome was in-hospital mortality. The area under the receiver operating characteristic curve was used to evaluate score performance.

RESULTS

One hundred forty-three patients, 79 pre-EGDT and 64 post-EGDT, were included. The mean age was 58 +/- 17 years, and pneumonia was the source of infection in 37%. The in-hospital mortality rate was 23%. The area under the receiver operating characteristic curve for MEDS to predict mortality was 0.61 (95% confidence interval [CI], 0.50-0.72) overall, 0.69 (95% CI, 0.56-0.82) in pre-EGDT patients, and 0.53 (95% CI, 0.33-0.74) in post-EGDT patients.

CONCLUSIONS

The MEDS score performed with poor accuracy for predicting mortality in ED patients with sepsis. These results suggest the need for further validation of the MEDS score before widespread clinical use.

Risk scoring and bloodstream infections

Risk-scoring systems are utilised in patients with bloodstream infections (BSI) to quantify disease-associated morbidity and mortality based on simple clinical or laboratory data usually obtained early in the course of illness. In order to reduce BSI-associated mortality, specific scores were elaborated to allow early diagnosis and prompt and appropriate antibiotic therapy. Risk scoring was also successfully derived and validated to identify patients at higher risk for antibiotic-resistant BSI, or colonisation, mainly due to methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. However, a major limitation of risk-scoring systems is the relevance to the local epidemiological environment and the difficulty in generalising results from a single study. Intelligence technology recently utilised scores to predict risks for specific pathogens causing BSI. An example of this innovation, the TREAT system, was able to significantly reduce mortality, length of hospitalisation and costs in patients with BSI. New randomised clinical trials are needed to study the efficacy of clinical scores in reducing BSI-associated morbidity and mortality.

Performance of severity of illness scoring systems in emergency department patients with infection

OBJECTIVES

To validate the Mortality in Emergency Department Sepsis (MEDS) score, the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older (CURB-65) score, and a modified Rapid Emergency Medicine Score (mREMS) in patients with suspected infection.

METHODS

This was a prospective cohort study. Adult patients with clinically suspected infection admitted from December 10, 2003, to September 30, 2004, in an urban emergency department with approximately 50,000 annual visits were eligible. The MEDS and CURB-65 scores were calculated as originally described, but REMS was modified in neurologic scoring because a full Glasgow Coma Scale score was not uniformly available. Discrimination of each score was assessed with the area under the receiver operating characteristics curve (AUC).

RESULTS

Of 2,132 patients, 3.9% (95% confidence interval [CI] = 3.1% to 4.7%) died. Mortality stratified by the MEDS score was as follows: 0-4 points, 0.4% (95% CI = 0.0 to 0.7%); 5-7 points, 3.3% (95% CI = 1.7% to 4.9%); 8-12 points, 6.6% (95% CI = 4.4% to 8.8%); and > or = 13 points, 31.6% (95% CI = 22.4% to 40.8%). Mortality stratified by CURB-65 was as follows: 0 points, 0% (0 of 457 patients); 1 point, 1.6% (95% CI = 0.6% to 2.6%); 2 points, 4.1% (95% CI = 2.3% to 6.0%); 3 points, 4.9% (95% CI = 2.8% to 6.9%); 4 points, 18.1% (95% CI = 11.9% to 24.3%); and 5 points, 28.0% (95% CI = 10.4% to 45.6%). Mortality stratified by the mREMS was as follows: 0-2 points, 0.6% (95% CI = 0 to 1.2%); 3-5 points, 2.0% (95% CI = 0.8% to 3.1%); 6-8 points, 2.3% (95% CI = 1.1% to 3.5%); 9-11 points, 7.1% (95% CI = 4.2% to 10.1%); 12-14 points, 20.0% (95% CI = 12.5% to 27.5%); and > or = 15 points, 40.0% (95% CI = 22.5% to 57.5%). The AUCs were 0.85, 0.80, and 0.79 for MEDS, mREMS, and CURB-65, respectively.

CONCLUSIONS

In this large cohort of patients with clinically suspected infection, MEDS, mREMS, and CURB-65 all correlated well with 28-day in-hospital mortality.