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

期刊： Critical Care

作者：Kordo Saeed, Darius Cameron Wilson et.al

发表时间：2019/02/08

数字识别码： 10.1186/s13054-019-2329-5

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所有感染都有可能出现危及生命的情况，这取决于感染有机体的毒性和随后的病理生理宿主反应。因此，早期诊断和评估感染的严重程度对于采取适当的治疗策略至关重要。

目前缺乏经过验证的用于评估急诊科疑似感染患者的潜在疾病进展和住院决策的工具。发表在开放获取期刊Critical Care的文章旨在确定合适的血液生物标志物（如Mid-Regional Proadrenomedullin（MR-proADM），Procalcitonin（PCT），乳酸盐和C-reactive protein（CRP））或临床评分（如Systemic Inflammatory Response Syndrome（SIRS），Sequential Organ Failure Assessment（SOFA），quick SOFA（qSOFA），National Early Warning Score（NEWS）和Severity Score for Community-Acquired Pneumonia（CRB-65）），来填补这一临床需求的空缺。欢迎点击“阅读全文”获取更多文章信息。

图1：. 图源、

本研究通过9个急诊科（EDs）的独立二级分析验证观察性衍生患者队列；使用Logistic和Cox回归、受试者工作特征曲线下面积（area under the receiver operating characteristic, AUROC）和Kaplan-Meier曲线来评估性能；并通过由28天死亡率、ICU入住和住院>10天组成的复合终点来确定疾病进展。

共对1175例衍生患者和896例验证患者分别进行了分析，其28天死亡率分别为7.1%和5.0%，住院率分别为77.9%和76.2%。在两个队列中，MR-proADM在预测28天死亡率和住院需求方面的准确性均最高。与MR-proADM 浓度较低（< 1.54 nmol/L）的患者亚组相比，MR-proADM浓度高（≥ 1.54 nmol/L）、生物标志浓度低（即PCT < 0.25 ng/mL，乳酸盐< 2.0 mmol/L 或CRP < 67 mg/L）或临床评分低（即SOFA < 2 分，qSOFA < 2分, NEWS < 4 分或 CRB-65 < 2分）的患者亚组都具有住院时间显著延长（p < 0.001）、ICU入住率显著较高（p < 0.001）、死亡风险升高（如SOFA，qSOFA 和NEWS的HR [95% CI]值分别为 45.5 [10.0–207.6]、23.4 [11.1–49.3] 和32.6 [9.4–113.6]）以及疾病进展事件明显更多（p < 0.001）等特点。通过使用衍生的MR-proADM临界值< 0.87 nmol/L（分别为15.0% 和16.6%），可以促进两个队列门诊治疗的增加，同时降低再入院率，并避免死亡病例。

在疑似感染的急诊科（ED）就诊患者中，血液生物标志物MR-proADM可以最准确地确定疾病进一步进展的可能性。因此，将其纳入到早期脓毒症控制方案中可能有助于快速决策，以便启动、升级或加强早期治疗策略，或确定适合门诊治疗的患者。

Critical Care是一本高质量的、同行评议国际临床医学期刊。本期刊旨在通过获取、讨论、分发以及推广与重症监护医生相关的循证医学信息，来提升重症患者的护理质量。Critical Care旨在提供有关重症监护领域的全面概述。

Citation Impact

6.959 - 2-year IF

6.880 - 5-year IF

2.313 - SNIP

2.540 - SJR

摘要：

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.

（来源：科学网）