Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients

Background

Stratifying patients with sepsis was the basis of the predisposition, infection, response and organ dysfunction (PIRO) concept, an attempt to resolve the heterogeneity in treatment response. The purpose of this study is to perform an independent validation of the PIRO staging system in an international cohort and explore its utility in the identification of patients in whom time to antibiotic treatment is particularly important.

Methods

Prospective international cohort study, conducted over a 6-month period in five Portuguese hospitals and one Australian institution. All consecutive adult patients admitted to selected wards or the intensive care, with infections that met the CDC criteria for lower respiratory tract, urinary, intra-abdominal and bloodstream infections were included.

Results

There were 1638 patients included in the study. Patients who died in hospital presented with a higher PIRO score (10 ± 3 vs 8 ± 4, p < 0.001). The observed mortality was 3%, 15%, 24% and 34% in stage I, II, III and IV, respectively, which was within the predicted intervals of the original model, except for stage IV patients that presented a lower mortality. The hospital survival rate was 84%. The application of the PIRO staging system to the validation cohort resulted in a positive predictive value of 97% for stage I, 91% for stage II, 85% for stage III and 66% for stage IV. The area under the receiver operating characteristics curve (AUROC) was 0.75 for the all cohort and 0.70 if only patients with bacteremia were considered. Patients in stage III and IV who did not have antibiotic therapy administered within the desired time frame had higher mortality rate than those who have timely administration of antibiotic.

Conclusions

To our knowledge, this is the first external validation of this PIRO staging system and it performed well on different patient wards within the hospital and in different types of hospitals. Future studies could apply the PIRO system to decision-making about specific therapeutic interventions and enrollment in clinical trials based on disease stage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00966-7.

The negative impact of antibiotic resistance

Antibacterial therapy is one of the most important medical developments of the twentieth century; however, the spread of resistance in healthcare settings and in the community threatens the enormous gains made by the availability of antibiotic therapy. Infections caused by resistant bacteria lead to up to two-fold higher rates of adverse outcomes compared with similar infections caused by susceptible strains. These adverse outcomes may be clinical or economic and reflect primarily the failure or delay of antibiotic treatment. The magnitude of these adverse outcomes will be more pronounced as disease severity, strain virulence, or host vulnerability increases. The negative impacts of antibacterial resistance can be measured at the patient level by increased morbidity and mortality, at the healthcare level by increased resource utilization, higher costs and reduced hospital activity and at the society level by antibiotic treatment guidelines favouring increasingly broad-spectrum empiric therapy. In this review we will discuss the negative impact of antibiotic resistance on patients, the healthcare system and society.

Interhospital Comparisons of Coronary Artery Bypass Graft Surgical Site Infection Rates Differ if Donor Sites Are Excluded

The advent of public reporting of hospital-acquired infection rates has sparked ongoing discussion about the most appropriate surveillance data to present. When we used different numerators to calculate rates of surgical site infection following coronary artery bypass graft surgery, we found that some hospitals' rates and their rankings were notably affected.

Compliance with surgical antibiotic prophylaxis--reporting from a statewide surveillance programme in Victoria, Australia

A statewide assessment of the compliance of surgical antibiotic prophylaxis (SAP) with guidelines was undertaken for large public hospitals in Victoria, Australia. This was carried out using data collected as part of a surveillance system for hospital-acquired infections. The study population comprised patients in Victorian public hospitals with >100 beds (N=27) undergoing cardiac surgical procedures, hip or knee arthroplasty, cholecystectomy, appendectomy, colon surgery or hysterectomy over a 21-month period. Australian guidelines recommend SAP for all 10 643 surgical procedures included in this study. Combining all procedures, 87% received SAP, the choice of antibiotic was concordant with guidelines for 53.3% of procedures, and the choice of antibiotic was considered to be 'adequate but not concordant' for 23.9% of procedures. SAP was considered to be inadequate for 18.9% of procedures. A large number of antibiotic regimens were utilized for cardiac and orthopaedic surgery. Documentation of timing of administration was not submitted for more than half of all procedures. Timing was concordant with guidelines for 76.4% of procedures when documented. Prophylactic antibiotic choice was generally more concordant with guidelines for cardiac and orthopaedic procedures than for other types of surgery. However, even for these procedures, where infections carry high morbidity, SAP was sometimes inadequate. Regular reporting on SAP compliance from data collected during surveillance for hospital-acquired infections is achievable. This should lead to improvements in both compliance and documentation.

Bacteraemia due to Stenotrophomonas maltophilia: an analysis of 45 episodes

OBJECTIVE

Stenotrophomonas maltophilia is an important nosocomial pathogen and a therapeutic challenge. A ten-year review of episodes of bacteraemia due to S. maltophilia was undertaken in light of reports of an increasing frequency of infection.

METHODS

A retrospective analysis of bloodstream infections due toS. maltophilia at a tertiary care hospital in Melbourne, Australia. Cases were identified via microbiology laboratory reports, and relevant clinical data were collected from the medical record of each patient.

RESULTS

Eighty per cent of these 45 episodes were nosocomial. The most common characteristics in cases of bacteraemia were the presence of an indwelling central venous catheter (CVC) (38/45, 84%) and previous antibiotic therapy (33/45, 73%). There were 8 deaths (8/44, 18%) within 7 days of bacteraemia. A significant correlation was found between deaths and a failure to remove the CVC (P = 0.01) or treat with appropriate antimicrobials (P = 0.01). Antibiotic susceptibility testing revealed that isolates were most sensitive to sulphamethoxazole (80%), chloramphenicol (75.5%) and ceftazidime (64.5%).

CONCLUSIONS

S. maltophilia is an important pathogen especially in the highly compromised host. Isolation of this organism from a blood culture should prompt a careful review of the patient with particular emphasis on removal of indwelling CVCs and commencement of appropriate antibiotic therapy.

Bursitis due to Mycobacterium goodii, a recently described, rapidly growing mycobacterium

We report a case of olecranon bursitis due to Mycobacterium goodii in a 60-year-old man. Prior to recognition of his infection, he received intrabursal steroids and underwent olecranon bursectomy. His infection was cured with antimicrobial therapy consisting of doxycycline and ciprofloxacin. This case illustrates that previously unrecognized members of the Mycobacterium smegmatis group of mycobacteria have pathogenic potential.

Impact of non-CTCL dermatologic diagnoses and adjuvant therapies on cutaneous T-cell lymphoma patients treated with total skin electron beam radiation therapy

PURPOSE

To evaluate the impact of pre-cutaneous T-cell lymphoma dermatologic diagnoses and adjuvant therapies on the relapse-free and overall survivals of patients treated with total skin electron beam therapy.

METHODS AND MATERIALS

Between 1974 and 1990, 164 patients were evaluated by members of Yale University School of Medicine departments of Dermatology and Therapeutic Radiology and treated with total skin electron beam therapy to a total dose of 3600 cGy. Patients who achieved a clinical complete response were offered doxorubicin/cyclophosphamide chemotherapy, extracorporeal photopheresis, or no systemic adjuvant therapy. The effects of TNM stage, antecedent non-T-cell lymphoma dermatologic diagnoses, and systemic adjuvant therapies were analyzed for their impact on relapse-free and overall survival.

RESULTS

In this cohort of patients, an antecedent dermatologic diagnosis of follicular mucinosis or lymphomatoid papulosis was significantly associated with a shorter relapse-free survival for T1 and T2 patients, while antecedent "non-specific" dermatitides were associated with a somewhat better relapse-free survival. When the impact of systemic adjuvant therapies was analyzed, neither systemic doxorubicin/cyclophosphamide chemotherapy nor systemic extracorporeal photopheresis were found to delay cutaneous relapse.

CONCLUSION

Our results suggest that antecedent follicular mucinosis and lymphomatoid papulosis may be associated with short relapse-free survival in T1 and T2 patients treated with total skin electron beam therapy. They also imply that neither adjuvant chemotherapy nor extracorporeal photopheresis delay cutaneous relapse after total skin electron beam therapy.