The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study.
- Saeed K Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK. kordosaeed@nhs.net.
- Wilson DC B·R·A·H·M·S GmbH, Hennigsdorf, Germany.
- Bloos F Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
- Schuetz P Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Switzerland.
- van der Does Y Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
- Melander O Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden.
- Hausfater P Emergency Department hôpital Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris and Sorbonne Universités GRC-14 BIOSFAST and INSERM UMR-S 1166, Paris, France.
- Legramante JM Emergency Department, Policlinico Tor Vergata, Rome, Italy.
- Claessens YE Department of Emergency Medicine, Monaco Princess Grace Hospital, Monaco, France.
- Amin D Department of Critical Care, Morton Plant Hospital, 300 Pinellas Street, Clearwater, FL, 33756, USA.
- Rosenqvist M Department of Clinical Sciences Malmö, Lund University, Lund, Sweden.
- White G Department of Blood Sciences, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK.
- Mueller B Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Switzerland.
- Limper M Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht University, Utrecht, Netherlands.
- Callejo CC Emergency Department, Hospital Clínico San Carlos, Madrid, Spain.
- Brandi A Emergency Department, Policlinico Tor Vergata, Rome, Italy.
- Macchi MA Department of Emergency Medicine, Monaco Princess Grace Hospital, Monaco, France.
- Cortes N Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK.
- Kutz A Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Switzerland.
- Patka P Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
- Yañez MC Emergency Department, Hospital Clínico San Carlos, Madrid, Spain.
- Bernardini S Department of Laboratory Medicine, Policlinico Tor Vergata, Rome, Italy.
- Beau N Department of Emergency Medicine, Monaco Princess Grace Hospital, Monaco, France.
- Dryden M Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK.
- van Gorp ECM Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
- Minieri M Department of Laboratory Medicine, Policlinico Tor Vergata, Rome, Italy.
- Chan L Department of accident and emergency, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK.
- Rood PPM Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
- Del Castillo JG Emergency Department, Instituto de Investigación Sanitaria (IdISSC), Hospital Clínico San Carlos, Madrid, Spain.
- 2019-02-10
Published in:
- Critical care (London, England). - 2019
Disease progression
Emergency department
MR-proADM
SOFA
Sepsis
qSOFA
Adolescent
Adrenomedullin
Adult
Aged
Aged, 80 and over
Area Under Curve
Biomarkers
C-Reactive Protein
Disease Progression
Early Diagnosis
Emergency Service, Hospital
England
Female
France
Humans
Infections
Italy
Lactic Acid
Logistic Models
Male
Middle Aged
Organ Dysfunction Scores
Peptide Fragments
Proportional Hazards Models
Protein Precursors
Spain
Statistics, Nonparametric
Sweden
Switzerland
Validation Studies as Topic
English
BACKGROUND
There is a lack of validated tools to assess potential disease progression and hospitalisation decisions in patients presenting to the emergency department (ED) with a suspected infection. This study aimed to identify suitable blood biomarkers (MR-proADM, PCT, lactate and CRP) or clinical scores (SIRS, SOFA, qSOFA, NEWS and CRB-65) to fulfil this unmet clinical need.
METHODS
An observational derivation patient cohort validated by an independent secondary analysis across nine EDs. Logistic and Cox regression, area under the receiver operating characteristic (AUROC) and Kaplan-Meier curves were used to assess performance. Disease progression was identified using a composite endpoint of 28-day mortality, ICU admission and hospitalisation > 10 days.
RESULTS
One thousand one hundred seventy-five derivation and 896 validation patients were analysed with respective 28-day mortality rates of 7.1% and 5.0%, and hospitalisation rates of 77.9% and 76.2%. MR-proADM showed greatest accuracy in predicting 28-day mortality and hospitalisation requirement across both cohorts. Patient subgroups with high MR-proADM concentrations (≥ 1.54 nmol/L) and low biomarker (PCT < 0.25 ng/mL, lactate < 2.0 mmol/L or CRP < 67 mg/L) or clinical score (SOFA < 2 points, qSOFA < 2 points, NEWS < 4 points or CRB-65 < 2 points) values were characterised by a significantly longer length of hospitalisation (p < 0.001), rate of ICU admission (p < 0.001), elevated mortality risk (e.g. SOFA, qSOFA and NEWS HR [95%CI], 45.5 [10.0-207.6], 23.4 [11.1-49.3] and 32.6 [9.4-113.6], respectively) and a greater number of disease progression events (p < 0.001), compared to similar subgroups with low MR-proADM concentrations (< 1.54 nmol/L). Increased out-patient treatment across both cohorts could be facilitated using a derivation-derived MR-proADM cut-off of < 0.87 nmol/L (15.0% and 16.6%), with decreased readmission rates and no mortalities.
CONCLUSIONS
In patients presenting to the ED with a suspected infection, the blood biomarker MR-proADM could most accurately identify the likelihood of further disease progression. Incorporation into an early sepsis management protocol may therefore aid rapid decision-making in order to either initiate, escalate or intensify early treatment strategies, or identify patients suitable for safe out-patient treatment.
There is a lack of validated tools to assess potential disease progression and hospitalisation decisions in patients presenting to the emergency department (ED) with a suspected infection. This study aimed to identify suitable blood biomarkers (MR-proADM, PCT, lactate and CRP) or clinical scores (SIRS, SOFA, qSOFA, NEWS and CRB-65) to fulfil this unmet clinical need.
METHODS
An observational derivation patient cohort validated by an independent secondary analysis across nine EDs. Logistic and Cox regression, area under the receiver operating characteristic (AUROC) and Kaplan-Meier curves were used to assess performance. Disease progression was identified using a composite endpoint of 28-day mortality, ICU admission and hospitalisation > 10 days.
RESULTS
One thousand one hundred seventy-five derivation and 896 validation patients were analysed with respective 28-day mortality rates of 7.1% and 5.0%, and hospitalisation rates of 77.9% and 76.2%. MR-proADM showed greatest accuracy in predicting 28-day mortality and hospitalisation requirement across both cohorts. Patient subgroups with high MR-proADM concentrations (≥ 1.54 nmol/L) and low biomarker (PCT < 0.25 ng/mL, lactate < 2.0 mmol/L or CRP < 67 mg/L) or clinical score (SOFA < 2 points, qSOFA < 2 points, NEWS < 4 points or CRB-65 < 2 points) values were characterised by a significantly longer length of hospitalisation (p < 0.001), rate of ICU admission (p < 0.001), elevated mortality risk (e.g. SOFA, qSOFA and NEWS HR [95%CI], 45.5 [10.0-207.6], 23.4 [11.1-49.3] and 32.6 [9.4-113.6], respectively) and a greater number of disease progression events (p < 0.001), compared to similar subgroups with low MR-proADM concentrations (< 1.54 nmol/L). Increased out-patient treatment across both cohorts could be facilitated using a derivation-derived MR-proADM cut-off of < 0.87 nmol/L (15.0% and 16.6%), with decreased readmission rates and no mortalities.
CONCLUSIONS
In patients presenting to the ED with a suspected infection, the blood biomarker MR-proADM could most accurately identify the likelihood of further disease progression. Incorporation into an early sepsis management protocol may therefore aid rapid decision-making in order to either initiate, escalate or intensify early treatment strategies, or identify patients suitable for safe out-patient treatment.
- Language
-
- English
- Open access status
- gold
- Identifiers
-
- DOI 10.1186/s13054-019-2329-5
- PMID 30736862
- Persistent URL
- https://sonar.ch/global/documents/555
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