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The early identification of disease progression in patients with suspected infection presenting to the emergency department : A multi-centre derivation and validation study

Saeed, Kordo (author)
University of Southampton,North Hampshire Hospital
Wilson, Darius Cameron (author)
Brahms GmbH
Bloos, Frank (author)
Universitätsklinikum Jena
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Schuetz, Philipp (author)
University of Basel,Cantonal Hospital Aarau
Van Der Does, Yuri (author)
Erasmus University Medical Center
Melander, Olle (author)
Lund University,Lunds universitet,Kardiovaskulär forskning - hypertoni,Forskargrupper vid Lunds universitet,Cardiovascular Research - Hypertension,Lund University Research Groups,Skåne University Hospital
Hausfater, Pierre (author)
Pitié-Salpêtrière University Hospital
Legramante, Jacopo M. (author)
University of Rome Tor Vergata,Tor Vergata University Hospital
Claessens, Yann Erick (author)
Monaco Princess Grace Hospital
Amin, Deveendra (author)
Morton Plant Hospital
Rosenqvist, Mari (author)
Lund University,Lunds universitet,Kardiovaskulär forskning - hypertoni,Forskargrupper vid Lunds universitet,Cardiovascular Research - Hypertension,Lund University Research Groups,Skåne University Hospital
White, Graham (author)
North Hampshire Hospital
Mueller, Beat (author)
University of Basel,Cantonal Hospital Aarau
Limper, Maarten (author)
University Medical Center Utrecht,Utrecht University
Callejo, Carlota Clemente (author)
Hospital Clinico San Carlos de Madrid
Brandi, Antonella (author)
Tor Vergata University Hospital
MacChi, Marc Alexis (author)
Monaco Princess Grace Hospital
Cortes, Nicholas (author)
University of Southampton,St Bernard's Hospital,North Hampshire Hospital
Kutz, Alexander (author)
Cantonal Hospital Aarau
Patka, Peter (author)
Erasmus University Medical Center
Yañez, María Cecilia (author)
Hospital Clinico San Carlos de Madrid
Bernardini, Sergio (author)
Tor Vergata University Hospital,University of Rome Tor Vergata
Beau, Nathalie (author)
Monaco Princess Grace Hospital
Dryden, Matthew (author)
Rare and imported pathogens laboratory (RIPL),North Hampshire Hospital,University of Southampton
Van Gorp, Eric C.M. (author)
Erasmus University Medical Center
Minieri, Marilena (author)
Tor Vergata University Hospital,University of Rome Tor Vergata
Chan, Louisa (author)
North Hampshire Hospital
Rood, Pleunie P.M. (author)
Erasmus University Medical Center
Del Castillo, Juan Gonzalez (author)
Hospital Clinico San Carlos de Madrid
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 (creator_code:org_t)
2019-02-08
2019
English.
In: Critical Care. - : Springer Science and Business Media LLC. - 1364-8535. ; 23:1
  • Journal article (peer-reviewed)
Abstract Subject headings
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  • 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.

Subject headings

MEDICIN OCH HÄLSOVETENSKAP  -- Klinisk medicin -- Anestesi och intensivvård (hsv//swe)
MEDICAL AND HEALTH SCIENCES  -- Clinical Medicine -- Anesthesiology and Intensive Care (hsv//eng)

Keyword

Disease progression
Emergency department
MR-proADM
qSOFA
Sepsis
SOFA

Publication and Content Type

art (subject category)
ref (subject category)

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