Sequential organ failure assessment (SOFA) scores differ between genders in a sepsis cohort: cause or effect?

Sex differences in the SOFA score of ICU patients with sepsis or septic shock: a nationwide analysis

BACKGROUND

The Sequential Organ Failure Assessment (SOFA) score is an important tool in diagnosing sepsis and quantifying organ dysfunction. However, despite emerging evidence of differences in sepsis pathophysiology between women and men, sex is currently not being considered in the SOFA score. We aimed to investigate potential sex-specific differences in organ dysfunction, as measured by the SOFA score, in patients with sepsis or septic shock and explore outcome associations.

METHODS

Retrospective analysis of sex-specific differences in the SOFA score of prospectively enrolled ICU patients with sepsis or septic shock admitted to one of 85 certified Swiss ICUs between 01/2021 and 12/2022.

RESULTS

Of 125,782 patients, 5947 (5%) were admitted with a clinical diagnosis of sepsis (2244, 38%) or septic shock (3703, 62%). Of these, 5078 (37% women) were eligible for analysis. A statistically significant difference of the total SOFA score on admission was found between women (mean 7.5 ± SD 3.6 points) and men (7.8 ± 3.6 points, Wilcoxon rank-sum p < 0.001). This was driven by differences in the coagulation (p = 0.008), liver (p < 0.001) and renal (p < 0.001) SOFA components. Differences between sexes were more prominent in younger patients < 52 years of age (women 7.1 ± 4.0 points vs men 8.1 ± 4.2 points, p = 0.004). No sex-specific differences were found in ICU length of stay (women median 2.6 days (IQR 1.3-5.3) vs men 2.7 days (IQR 1.2-6.0), p = 0.13) and ICU mortality (women 14% vs men 15%, p = 0.17).

CONCLUSION

Sex-specific differences exist in the SOFA score of patients admitted to a Swiss ICU with sepsis or septic shock, particularly in laboratory-based components. Although the clinical meaningfulness of these differences is unclear, a reevaluation of sex-specific thresholds for SOFA score components is warranted in an attempt to make more accurate and individualised classifications.

Sex and gender differences in intensive care medicine

Despite significant advancements in critical care medicine, limited attention has been given to sex and gender disparities in management and outcomes of patients admitted to the intensive care unit (ICU). While "sex" pertains to biological and physiological characteristics, such as reproductive organs, chromosomes and sex hormones, "gender" refers more to sociocultural roles and human behavior. Unfortunately, data on gender-related topics in the ICU are lacking. Consequently, data on sex and gender-related differences in admission to the ICU, clinical course, length of stay, mortality, and post-ICU burdens, are often inconsistent. Moreover, when examining specific diagnoses in the ICU, variations can be observed in epidemiology, pathophysiology, presentation, severity, and treatment response due to the distinct impact of sex hormones on the immune and cardiovascular systems. In this narrative review, we highlight the influence of sex and gender on the clinical course, management, and outcomes of the most encountered intensive care conditions, in addition to the potential co-existence of unconscious biases which may also impact critical illness. Diagnoses with a known sex predilection will be discussed within the context of underlying sex differences in physiology, anatomy, and pharmacology with the goal of identifying areas where clinical improvement is needed. To optimize patient care and outcomes, it is crucial to comprehend and address sex and gender differences in the ICU setting and personalize management accordingly to ensure equitable, patient-centered care. Future research should focus on elucidating the underlying mechanisms driving sex and gender disparities, as well as exploring targeted interventions to mitigate these disparities and improve outcomes for all critically ill patients.

Sex-related differences in adult patients with status epilepticus: a seven-year two-center observation

BACKGROUND

Conflicting findings exist regarding the influence of sex on the development, treatment, course, and outcome of status epilepticus (SE). Our study aimed to investigate sex-related disparities in adult SE patients, focusing on treatment, disease course, and outcome at two Swiss academic medical centers.

METHODS

In this retrospective study, patients treated for SE at two Swiss academic care centers from Basel and Geneva from 2015 to 2021 were included. Primary outcomes were return to premorbid neurologic function, death during hospital stay and at 30 days. Secondary outcomes included characteristics of treatment and disease course. Associations with primary and secondary outcomes were assessed using multivariable logistic regression. Analysis using propensity score matching was performed to account for the imbalances regarding age between men and women.

RESULTS

Among 762 SE patients, 45.9% were women. No sex-related differences were found between men and women, except for older age and lower frequency of intracranial hemorrhages in women. Compared to men, women had a higher median age (70 vs. 66, p = 0.003), had focal nonconvulsive SE without coma more (34.9% vs. 25.5%; p = 0.005) and SE with motor symptoms less often (52.3% vs. 63.6%, p = 0.002). With longer SE duration (1 day vs. 0.5 days, p = 0.011) and a similar proportion of refractory SE compared to men (36.9% vs. 36.4%, p = 0.898), women were anesthetized and mechanically ventilated less often (30.6% vs. 42%, p = 0.001). Age was associated with all primary outcomes in the unmatched multivariable analyses, but not female sex. In contrast, propensity score-matched multivariable analyses revealed decreased odds for return to premorbid neurologic function for women independent of potential confounders. At hospital discharge, women were sent home less (29.7% vs. 43.7%, p < 0.001) and to nursing homes more often (17.1% vs. 10.0%, p = 0.004).

CONCLUSIONS

This study identified sex-related disparities in the clinical features, treatment modalities, and outcome of adult patients with SE with women being at a disadvantage, implying that sex-based factors must be considered when formulating strategies for managing SE and forecasting outcomes.

Sex differences in clinical presentation and mortality in emergency department patients with sepsis

BACKGROUND

There is growing awareness that sex differences are associated with different patient outcomes in a variety of diseases. Studies investigating the effect of patient sex on sepsis-related mortality remain inconclusive and mainly focus on patients with severe sepsis and septic shock in the intensive care unit. We therefore investigated the association between patient sex and both clinical presentation and 30-day mortality in patients with the whole spectrum of sepsis severity presenting to the emergency department (ED) who were admitted to the hospital.

MATERIALS AND METHODS

In our multi-centre cohort study, we retrospectively investigated adult medical patients with sepsis in the ED. Multivariable analysis was used to evaluate the association between patient sex and all-cause 30-day mortality.

RESULTS

Of 2065 patients included, 47.6% were female. Female patients had significantly less comorbidities, lower Sequential Organ Failure Assessment score and abbreviated Mortality Emergency Department Sepsis score, and presented less frequently with thrombocytopenia and fever, compared to males. For both sexes, respiratory tract infections were predominant while female patients more often had urinary tract infections. Females showed lower 30-day mortality (10.1% vs. 13.6%; p = .016), and in-hospital mortality (8.0% vs. 11.1%; p = .02) compared to males. However, a multivariable logistic regression model showed that patient sex was not an independent predictor of 30-day mortality (OR 0.90; 95% CI 0.67-1.22; p = .51).

CONCLUSIONS

Females with sepsis presenting to the ED had fewer comorbidities, lower disease severity, less often thrombocytopenia and fever and were more likely to have a urinary tract infection. Females had a lower in-hospital and 30-day mortality compared to males, but sex was not an independent predictor of 30-day mortality. The lower mortality in female patients may be explained by differences in comorbidity and clinical presentation compared to male patients.KEY MESSAGESOnly limited data exist on sex differences in sepsis patients presenting to the emergency department with the whole spectrum of sepsis severity.Female sepsis patients had a lower incidence of comorbidities, less disease severity and a different source of infection, which explains the lower 30-day mortality we found in female patients compared to male patients.We found that sex was not an independent predictor of 30-day mortality; however, the study was probably underpowered to evaluate this outcome definitively.

The influence of inflammation on cardiovascular disease in women

The onset of cardiovascular disease in women is almost a decade later than men, partly due to the protective effect of estrogen prior to menopause. Recently, it was noted that while there have been advances in improving the morbidity and mortality from CVD in women older than 55 years, the improvement in younger women has been stagnant. The mechanism behind this lag is unclear. This manuscript reviews the literature available on the sex-specific inflammatory response in the context of traditional and non-traditional cardiovascular disease risk factors. Our review suggests that women have a differential inflammatory response to various disease states that increases their risk for CVD and warrants a distinct prioritization from men when calculating cardiovascular disease risk.

Race and sex based disparities in sepsis

BACKGROUND

Studies of sepsis evaluating sex- and race-related disparities in treatment and outcome have been limited by using administrative databases, which may not adequately capture sepsis diagnosis, used limited number and types of races, or not included both sex and race in the analyses.

OBJECTIVE

To determine if patients of different races and sexes with sepsis have different mortality, receipt of mechanical ventilation or renal replacement therapy, or time to antibiotics?

METHODS

We retrospectively analyzed clinical data from 34,999 patients with sepsis, defined by Sepsis-3 criteria, using logistic regression and linear regression.

RESULTS

After adjustments for confounders, Asian females had the lowest adjusted 90-day mortality (OR=0.656, 95% CI=0.385-1.118, p<0.001 compared to White males). Similarly, compared to White males, African-American males had a lower adjusted mortality (OR=0.790, 95% CI=0.648-0.963, p = 0.019), while Asian males (OR=1.185, 95% CI=0. 828-1.696, p = 0.354) and both African-American (OR=0.972, 95% CI=0.800-1.182, p = 0.779) and Caucasian (OR=1.054, 95% CI=0.960-1.158, p = 0.270) females had similar mortality. Both male and female patients with Other/unknown race had higher mortality (OR=1.776, 95% CI=1.395-2.261, p<0.001 and OR=1.658, 95% CI=1.359-2.021, p<0.001), respectively. In the secondary analyses for new-onset mechanical ventilation and new-onset renal replacement therapy post-sepsis, we found no association between any of the race-sex groups and receipt of these therapies.

CONCLUSION

We found that Asian females had the lowest adjusted 90-day mortality for patients with sepsis. Understanding the reasons for disparities in outcome after sepsis may improve care and outcomes in diverse populations.

Propensity-Score Analysis Reveals that Sex is Not a Prognostic Factor for Mortality in Intensive Care Unit-Admitted Patients with Septic Bacteremia

OBJECTIVE

Men have been considered to have a higher incidence of infectious diseases, with controversy over the possibility that sex could influence the prognosis of the infection. This study aimed to explore this assumption in patients admitted to the intensive care unit (ICU) with septic bacteremia.

METHODS

A retrospective analysis (2006-2017) of septic patients with microbiologically confirmed bacteremia (n=440) was performed. Risk of ICU and in-hospital mortality in males versus females was compared by univariate analysis and a propensity score analysis integrating their clinical characteristics.

RESULTS

Sepsis more frequently occurred in males (80.2% vs 76.1%) as well as in-hospital (48.0% vs 41.3%) and ICU (39.9% vs 36.5%) mortality. Univariate analyses showed that males had a higher Charlson comorbidity index and worse McCabe prognostic score. However, the propensity score in 296 matched patients demonstrated that females had higher risk of both ICU (OR 1.39; 95% CI 0.89-2.19) and in-hospital mortality (OR 1.18; 95% CI 0.77-1.83), but without statistical significance.

CONCLUSION

Males with sepsis had worse clinical characteristics when admitted to the ICU, but sex had no influence on mortality. These data contribute to helping reduce the sex-dependent gap present in healthcare provision.

Gender differences in the provision of intensive care: a Bayesian approach

PURPOSE

It is currently unclear whether management and outcomes of critically ill patients differ between men and women. We sought to assess the influence of age, sex and diagnoses on the probability of intensive care provision in critically ill cardio- and neurovascular patients in a large nationwide cohort in Switzerland.

METHODS

Retrospective analysis of 450,948 adult patients with neuro- and cardiovascular disease admitted to all hospitals in Switzerland between 01/2012 and 12/2016 using Bayesian modeling.

RESULTS

For all diagnoses and populations, median ages at admission were consistently higher for women than for men [75 (64;82) years in women vs. 68 (58;77) years in men, p < 0.001]. Overall, women had a lower likelihood to be admitted to an intensive care unit (ICU) than men, despite being more severely ill [odds ratio (OR) 0.78 (0.76-0.79)]. ICU admission probability was lowest in women aged > 65 years (OR women:men 0.94 (0.89-0.99), p < 0.001). Women < 45 years had a similar ICU admission probability as men in the same age category [OR women:men 1.03 (0.94-1.13)], in spite of more severe illness. The odds to die were significantly higher in women than in men per unit increase in Simplified Acute Physiology Score (SAPS) II (OR 1.008 [1.004-1.012]).

CONCLUSION

In the care of the critically ill, our study suggests that women are less likely to receive ICU treatment regardless of disease severity. Underuse of ICU care was most prominent in younger women < 45 years. Although our study has several limitations that are imposed by the limited data available from the registries, our findings suggest that current ICU triage algorithms could benefit from careful reassessment. Further, and ideally prospective, studies are needed to confirm our findings.

Gender-related differences in the performance of sequential organ failure assessment (SOFA) to predict septic shock after percutaneous nephrolithotomy

The study aims to identify whether gender differences exist in the sequential organ failure assessment (SOFA) score to the extent of affecting its predictive accuracy for septic shock after percutaneous nephrolithotomy (PCNL). A retrospective study of 612 patients undergoing PCNL was performed. The SOFA scores of male and female groups were compared to identify any gender differences. The ROC curve was used to find differences between the original and adjusted SOFA scores. Postoperative septic shock developed in 21 (3.43%) cases. A marginally significant discrepancy in median SOFA scores between genders was discovered in a subgroup of patients < 40 years old (p = 0.048). A gender difference existed in the SOFA score after PCNL, with greater proportion of high scores in female patients (p = 0.011). Male patients had a higher proportion of ≥ 2 sub-score in hepatic and renal systems than female patients, caused by their higher preoperative bilirubin and creatinine (p < 0.05). An adjusted SOFA score was created to replace the original postoperative SOFA score with the perioperative changed values of bilirubin and creatinine. Performance of the adjusted SOFA score for predicting septic shock was comparable with the original SOFA score (AUC 0.987 vs. 0.985, p = 0.932). Under the premise of ensuring 100% sensitivity, the adjusted SOFA score reduced the 43.7% (31/71) false-positive rate for predicting septic shock compared with the original SOFA score. In conclusion, the gender should not be neglected when applying SOFA score for patients after PCNL. The adjusted SOFA score eliminates negative effects caused by gender differences in predicting septic shock.

Gender differences in mortality and quality of life after septic shock: A post-hoc analysis of the ARISE study

PURPOSE

To assess the impact of gender and pre-menopausal state on short- and long-term outcomes in patients with septic shock.

MATERIAL AND METHODS

Cohort study of the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial, an international randomized controlled trial comparing early goal-directed therapy (EGDT) to usual care in patients with early septic shock, conducted between October 2008 and April 2014. The primary exposure in this analysis was legal gender and the secondary exposure was pre-menopausal state defined by chronological age (≤ 50 years).

RESULTS

641 (40.3%) of all 1591 ARISE trial participants in the intention-to-treat population were females and overall, 337 (21.2%) (146 females) patients were 50  years of age or younger. After risk-adjustment, we could not identify any survival benefit for female patients at day 90 in the younger (≤50 years) (adjusted Odds Ratio (aOR): 0.91 (0.46-1.89), p = .85) nor in the older (>50 years) age-group (aOR: 1.10 (0.81-1.49), p = .56). Similarly, there was no gender-difference in ICU, hospital, 1-year mortality nor quality of life measures.

CONCLUSIONS

This post-hoc analysis of a large multi-center trial in early septic shock has shown no short- or long-term survival effect for women overall as well as in the pre-menopausal age-group.

Sex differences in crude mortality rates and predictive value of intensive care unit-based scores when applied to the cardiac intensive care unit

BACKGROUND

Limited data exists regarding sex differences in outcome and predictive accuracy of intensive care unit-based scoring systems when applied to cardiac intensive care unit patients.

METHODS

We reviewed medical records of patients admitted to cardiac intensive care unit from 1 January 2011-31 December 2016. Sex differences in mortality rates and the performance of intensive care unit-based scoring systems in predicting in-hospital mortality were analyzed. Calibration was assessed by the Hosmer-Lemeshow test and locally weighted scatterplot smoothing curves. Discrimination was assessed using the c statistic and receiver-operating characteristic curve.

RESULTS

Among 6963 patients, 2713 (39%) were women. Overall in-hospital and cardiac intensive care unit mortality rates were similar in women and men (9.1% vs 9.4%, p=0.67 and 5.9% vs 6%, p=0.88, respectively) and in age and major diagnosis subgroups. Of the scoring systems, Acute Physiology and Chronic Health Evaluation III and Sequential Organ Failure Assessment had poor calibration (Hosmer-Lemeshow p value <0.001), while Simplified Acute Physiology Score II performed better (Hosmer-Lemeshow p value 0.09), in both women and men. All scores had good discrimination (C statistics >0.8). In the subgroups of acute myocardial infarction and heart failure patients, all scores had good calibration (Hosmer-Lemeshow p>0.001) and discrimination (C statistic >0.8) while in diagnosis subgroups with highest mortality, the calibration varied among scores and by sex, and discrimination was poor.

CONCLUSIONS

No sex differences in mortality were seen in cardiac intensive care unit patients. The mortality predictive value of intensive care unit-based scores is limited in both sexes and variable among different subgroups of diagnoses.

Does Gender Matter in Septic Patient Outcomes?

PURPOSE

The purpose of this study was to examine potential gender disparities in relation to factors associated with sepsis management among a cohort of patients admitted through an emergency department with a discharge diagnosis of severe sepsis or septic shock. Sepsis is one of the leading causes of death globally, with significant associated costs. Predictors of survival for those with sepsis-related diagnoses are complex.

DESIGN AND METHODS

The study had a retrospective, descriptive cross-sectional design. The sample (N = 482) included patients 18 years of age or older who presented to the emergency department of a nonprofit, Magnet-recognized, acute care hospital located in southern California. Subjects included those who subsequently met the criteria for a discharge diagnosis of severe sepsis or septic shock as defined by the Surviving Sepsis Campaign. Patient characteristics, clinical variables, care management processes, and outcomes were extracted from the electronic health record. A multivariate model was analyzed.

FINDINGS

The sample included 234 women (48.5%) and 248 men (51.5%). Logistic regression with eight independent variables (discharge diagnosis, age, comorbidities, length of hospital stay, source of infection, first serum lactate level measured, recommended fluids administered, and gender) reliably predicted odds for patient survival, ϰ² (12) = 118.38, p < .001, and correctly classified 77.3% of cases. All eight independent variables significantly contributed to the model. Men had a higher likelihood of hospital survival than women (odds ratio 1.68; 95% confidence interval 1.01-2.79; p = .045).

CONCLUSIONS

The Surviving Sepsis Campaign has provided a clear pathway for care of patients with sepsis-related diagnoses. Therapeutic strategies should be developed to address differences in outcome by gender. The adoption of more aggressive applications of evidence-based interventions for these patients may result in better patient outcomes.

CLINICAL RELEVANCE

Providers should understand the importance of adhering to sepsis protocols, minimizing treatment disparities, and recognizing gender differences.

The Outcomes of Pediatric Hematopoietic Stem Cell Transplantation Recipients Requiring Intensive Care Unit Admission- A Single Center Experience

BACKGROUND

Although the outcome of pediatric hematopoietic stem cell transplantation (HSCT) has significantly improved, it remains to be associated with high mortality. Identifying patients at high risk of mortality may potentially help to triage clinical management. The primary objective of this study is to evaluate risk factors associated with mortality of patients who received HSCT and admitted to ICU using pediatric sequential organ failure assessment (pSOFA), one of pediatric severity scoring systems in intensive care unit (ICU).

METHODS

We performed retrospective review of electronic medical records of pediatric patients who received HSCT and were admitted to ICU in our institution between January 2010 and June 2018. Incidence of mortality was obtained, and risk factors associated with the mortality were examined using univariate and multivariable analyses.

RESULTS

The mortality rate of pediatric HSCT patients who were admitted to ICU as a whole was 27.9%. Patients were divided into three groups based on the number of HSCT required and timing of ICU admission. Patients who received first HSCT and admitted to ICU during the same hospital stay were the majority of the study population (Group A). d(pSOFA), which was defined as the difference between maximum pSOFA and admission pSOFA, greater than and equal to 7 best predicted mortality of Group A (the area under the ROC curve 0.850; 95% CI: 0.733-0.966). Univariate and multivariable analyses showed that an increase in neurologic and cardiovascular sub scores were independently associated with higher mortality (odds ratio (OR) 2.27; 95% CI: 1.32-3.93, and OR 2.69; 95% CI: 1.21-5.99, respectively).

DISCUSSION

In our single center study, pediatric HSCT patients who were admitted to ICU demonstrated a high mortality. Risk factor analysis demonstrated that patients with the progression of neurologic and cardiovascular injuries probed by pSOFA scoring system during their ICU stay were strongly associated with mortality.

Systematic Review of Gender Differences in Sepsis Management and Outcomes

PURPOSE

Contributors to disparities in sepsis management have been attributed to genetic susceptibility, differences in clinical presentation, and healthcare delivery. The influence of gender on survival or mortality of patients with sepsis-related diagnoses is unclear. The purpose of the current study was to systematically review published research to identify factors and outcomes associated with sepsis management and outcomes based on gender differences.

METHODS

Covering a period from 2006 to 2016, a literature search was conducted on four electronic data bases including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCO, MedlinePlus, and PubMed. Content analysis of each article was performed independently by two authors. The guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was the method used to assess the quality of evidence of the articles in this review.

FINDINGS

A full review was completed on a total of 452 identified potentially relevant publications, and 7 publications met inclusion criteria. The methodological approaches included prospective and retrospective observational studies, and prospective and historical cohort studies. The aim of these studies was to identify if gender differences exist related to sepsis-related mortality, completion of Surviving Sepsis Campaign resuscitation bundle elements, sepsis-related care processes, and sepsis-related incidence and source.

CONCLUSIONS

Clinical sepsis studies evaluating gender and sepsis-related management and mortality are inconclusive and complex. Three different outcomes exist: no difference, higher risk in females, or higher risk in males. Further studies are needed to support the presence of gender disparities on sepsis-related healthcare outcomes.

CLINICAL RELEVANCE

Providers should understand the importance of adhering to sepsis protocols and minimizing treatment disparities including gender differences.