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Critical Care
Published in: Critical Care 1/2019

Open Access 01-12-2019 | Antibiotic | Research

Biomarkers and clinical scores to identify patient populations at risk of delayed antibiotic administration or intensive care admission

Authors: Juan Gonzalez del Castillo, Darius Cameron Wilson, Carlota Clemente-Callejo, Francisco Román, Ignasi Bardés-Robles, Inmaculada Jiménez, Eva Orviz, Macarena Dastis-Arias, Begoña Espinosa, Fernando Tornero-Romero, Jordi Giol-Amich, Veronica González, Ferran Llopis-Roca, on behalf of the INFURG-SEMES investigators

Published in: Critical Care | Issue 1/2019

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Abstract

Background

The performance of blood biomarkers (mid-regional proadrenomedullin (MR-proADM), procalcitonin (PCT), C-reactive protein (CRP), and lactate) and clinical scores (Sequential Organ Failure Assessment (SOFA), National Early Warning Score (NEWS), and quick SOFA) was compared to identify patient populations at risk of delayed treatment initiation and disease progression after presenting to the emergency department (ED) with a suspected infection.

Methods

A prospective observational study across three EDs. Biomarker and clinical score values were calculated upon presentation and 72 h, and logistic and Cox regression used to assess the strength of association. Primary outcomes comprised of 28-day mortality prediction and delayed antibiotic administration or intensive care (ICU) admission, whilst secondary outcomes identified subsequent disease progression.

Results

Six hundred eighty-four patients were enrolled with hospitalisation, ICU admission, and infection-related 28-day mortality rates of 72.8%, 3.4%, and 4.4%, respectively. MR-proADM and NEWS had the strongest association with hospitalisation and the requirement for antibiotic administration, whereas MR-proADM alone had the strongest association with ICU admission (OR [95% CI]: 5.8 [3.1 - 10.8]) and mortality (HR [95% CI]: 3.8 [2.2 - 6.5]). Patient subgroups with high MR-proADM concentrations (≥ 1.77 nmol/L) and low NEWS (< 5 points) values had significantly higher rates of ICU admission (8.1% vs 1.6%; p < 0.001), hospital readmission (18.9% vs. 5.9%; p < 0.001), infection-related mortality (13.5% vs. 0.2%; p < 0.001), and disease progression (29.7% vs. 4.9%; p < 0.001) than corresponding patients with low MR-proADM concentrations. ICU admission was delayed by 1.5 [0.25 – 5.0] days in patients with high MR-proADM and low NEWS values compared to corresponding patients with high NEWS values, despite similar 28-day mortality rates (13.5% vs. 16.5%). Antibiotics were withheld in 17.4% of patients with high MR-proADM and low NEWS values, with higher subsequent rates of ICU admission (27.3% vs. 4.8%) and infection-related hospital readmission (54.5% vs. 14.3%) compared to those administered antibiotics during ED treatment.

Conclusions

Patients with low severity signs of infection but high MR-proADM concentrations had an increased likelihood of subsequent disease progression, delayed antibiotic administration or ICU admission. Appropriate triage decisions and the rapid use of antibiotics in patients with high MR-proADM concentrations may constitute initial steps in escalating or intensifying early treatment strategies.
Appendix
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Metadata
Title
Biomarkers and clinical scores to identify patient populations at risk of delayed antibiotic administration or intensive care admission
Authors
Juan Gonzalez del Castillo
Darius Cameron Wilson
Carlota Clemente-Callejo
Francisco Román
Ignasi Bardés-Robles
Inmaculada Jiménez
Eva Orviz
Macarena Dastis-Arias
Begoña Espinosa
Fernando Tornero-Romero
Jordi Giol-Amich
Veronica González
Ferran Llopis-Roca
on behalf of the INFURG-SEMES investigators
Publication date
01-12-2019
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2019
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-019-2613-4

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