• Kordo Saeed, Darius Cameron Wilson, Frank Bloos, Philipp Schuetz, Yuri van der Does, Olle Melander, Pierre Hausfater, Jacopo M Legramante, Yann-Erick Claessens, Deveendra Amin, Mari Rosenqvist, Graham White, Beat Mueller, Maarten Limper, Carlota Clemente Callejo, Antonella Brandi, Marc-Alexis Macchi, Nicholas Cortes, Alexander Kutz, Peter Patka, María Cecilia Yañez, Sergio Bernardini, Nathalie Beau, Matthew Dryden, van Gorp Eric C M ECM Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands. , Marilena Minieri, Louisa Chan, Rood Pleunie P M PPM Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands., and Juan Gonzalez Del Castillo.
• Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK. kordosaeed@nhs.net.
• Crit Care. 2019 Feb 8; 23 (1): 40.

BackgroundThere 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.MethodsAn 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.ResultsOne 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.ConclusionsIn 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.

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