Prediction of Mortality in Febrile Medical Patients: How Useful Are Systemic Inflammatory Response Syndrome and Sepsis Criteria?

doi:10.1378/chest.113.6.1533

Chest

Volume 113, Issue 6, June 1998, Pages 1533-1541

https://doi.org/10.1378/chest.113.6.1533 Get rights and content

Study objectives

The aim was to evaluate demographic, clinical, and laboratory variables in febrile patients, with or without a microbiologically confirmed infection, for prediction of death, in comparison to the systemic inflammatory response syndrome (SIRS) and its criteria, such as abnormal temperature, tachycardia, tachypnea, and abnormal WBC count, and to sepsis, that includes SIRS and an infection.

Design

A prospective cohort study.

Setting

Department of internal medicine at a university hospital.

Patients

In 300 consecutive, hospitalized medical patients with new onset of fever, demographic, clinical, and laboratory variables were obtained during the 2 days after inclusion, while microbiological results for a follow-up period of 7 days were collected. Patients were followed up for survival or death, up to a maximum of 28 days after inclusion.

Measurements and results

Of all patients, 95% had SIRS, 44% had sepsis with a microbiologically confirmed infection, and 9% died. A model with a set of variables all significantly (p<0.01) contributing to the prediction of mortality was derived. The set included the presence of hospital-acquired fever, the peak respiratory rate, the nadir score on the Glasgow coma scale, and the nadir albumin plasma level within the first 2 days after inclusion. This set of variables predicted mortality for febrile patients with microbiologically confirmed infection even better. The predictive values for mortality of SIRS and sepsis were less than that of our set of variables.

Conclusions

In comparison to SIRS and sepsis, the new set of variables predicted mortality better for all patients with fever and also for those with microbiologically confirmed infection only. This type of effort may help in refining definitions of SIRS and sepsis, based on prognostically important demographic, clinical, and laboratory variables that are easily obtainable at the bedside.

Section snippets

MATERIALS AND METHODS

During a 1-year period, 300 consecutive patients with newly onset fever (temperature ≥38.0°C axillary or ≥38.3°C rectal) admitted to the Department of Internal Medicine of a university hospital were prospectively included in this observational study. The study had been approved by the local committee on ethics. Informed consent from each patient or closest relative was obtained before inclusion. The exclusion criteria were pregnancy, shock, and a life expectancy of <24 h. Moreover, patients who

Patient Characteristics

Table 1 describes some patient characteristics. Most patients (n=236) were initially admitted to a general internal medicine ward, 38 patients were admitted into the pulmonology ward, 10 patients were admitted into the oncology ward, and 16 patients were admitted into the medical ICU. Two hundred thirteen (71%) patients had a presumed focus of infection (Table 2). The median follow-up period was 5 (range, 1 to 28) days in nonsurvivors (n=27) and 8 (range, 1 to 28) days in survivors (n=273). No

DISCUSSION

In this study, the mortality rate of febrile patients with sepsis was higher than of those with SIRS and this was mainly accounted for by the predictive value for death of tachypnea. Supplementation by criteria such as mental changes, hypoalbuminemia, and the hospital as the location of fever onset greatly enhanced the predictive power of tachypnea. Hence, the SIRS and sepsis definitions could be refined to include the latter variables to improve the ability of identifying febrile patients who

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This was a retrospective chart review of adult patients ≥ 18 years of age, meeting qSOFA criteria and presenting to the emergency department between 1/01/2014 and 6/30/2016. Subjects were identified through an electronic query of the EMS record repository.
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Because of time restriction and overcrowding in the ED, there might be some patients overlooked. The authors were aware that SIRS is not a reliable criterion in cancer patients.28 Nevertheless, it was preferred for homogeneity for inclusion criteria to provide reliable comparison among studies.29
Differentiating sepsis from other noninfectious causes of systemic inflammatory response syndrome (SIRS) in cancer patients is often challenging. Although lactate and procalcitonin have been studied extensively regarding sepsis management, little is known about their utility in cancer patients.
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This prospective case-control study was conducted with adult cancer patients presenting to emergency department (ED) with at least two SIRS criteria. The infection status of each patient was determined retrospectively.
Main diagnostic variables were calculated for diagnostic and prognostic utilities of lactate and procalcitonin.
Among 86 patients, mean age was 61. Twenty-two (25.6%) were determined in the sepsis group.
In the ROC analysis, a lactate value of 1 mmol/L predicted sepsis with 86.36% (95%CI: 65.1%–97.1%) sensitivity and 28.12% (95%CI: 17.6%–40.76%) specificity. A procalcitonin value of 0.8 ng/mL yielded a sensitivity of 63.64% (95%CI: 40.7%–82.8%) and 76.56% (95%CI: 63.4%–86.2%) specificity for differential diagnosis of sepsis in cancer patients.
Lactate and procalcitonin showed similar abilities in differentiating sepsis from non-infective SIRS in cancer patients [AUROCs of 0.638 (95%CI:0.527–0.739) vs 0.637 (95%CI:0.527–0.738), respectively. p = 0.994].
They were also similar in predicting poor clinical outcome with AUROCs of 0.629 (95%CI:0.518–0.731) and 0.584 (95%CI: 0.473–0.69), respectively (p = 0.577).
The results of this study indicated that, none of the lactate and procalcitonin can be recommended alone to differentiate sepsis from non-infectious SIRS and to predict the poor clinical outcomes in adult cancer patients with SIRS in the ED.
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Although the SIRS criteria do have the prognostic value of defining a group of patients who are at an increased risk of developing complications and with increased mortality,10,11,12 they have been criticized for being too sensitive and nonspecific to be of much clinical use.13 Most ICU patients and many general ward patients meet the SIRS criteria.12,14,15,16 In the Sepsis Occurrence in Acutely ill Patients study, 93% of ICU admissions had at least two SIRS criteria at some point during their ICU stay.12
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Are the Concepts of SIRS and MODS Useful in Sepsis?
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View all citing articles on Scopus

: Financial support was provided by Grant No. 28-2275 from the Dutch Het Praeventiefonds.

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Chest

Clinical Investigations: Inflammation/InfectionPrediction of Mortality in Febrile Medical Patients: How Useful Are Systemic Inflammatory Response Syndrome and Sepsis Criteria?

Study objectives

Design

Setting

Patients

Measurements and results

Conclusions

Section snippets

MATERIALS AND METHODS

Patient Characteristics

DISCUSSION

Am J Med

Chest

Am J Med

Lancet

Am J Med

Manifestations of sepsis.

Arch Intern Med

Impact of temperature elevation on immunologic defenses.

Rev Infect Dis

Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.

Crit Care Med

The natural history of the systemic inflammatory response syndrome (SIRS): a prospective study.

JAMA

Sepsis syndrome: a valid clinical entity.

Crit Care Med

Toward an epidemiology and natural history of SIRS (systemic inflammatory response syndrome).

JAMA

The sepsis syndrome in a Dutch university hospital.

Arch Intern Med

Long-term survival and function after suspected Gram-negative sepsis.

JAMA

Systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock: incidence, morbidities and outcome in surgical ICU patients.

Intensive Care Med

The Italian SEPSIS study: preliminary results on the incidence and evolution of SIRS, sepsis, severe sepsis and septic shock.

Intensive Care Med

Bacteremia and severe sepsis in adults: a multicenter prospective survey in ICUs and wards of 24 hospitals.

Am J Respir Crit Care Med

The systemic inflammatory response syndrome as a predictor of bacteraemia and outcome from sepsis.

Q J Med

Clinical Investigations: Inflammation/Infection
Prediction of Mortality in Febrile Medical Patients: How Useful Are Systemic Inflammatory Response Syndrome and Sepsis Criteria?