Development and validation of an emergency bloodstream infection score for predicting in-hospital mortality in patients with community-acquired bloodstream infections

doi:10.5847/wjem.j.1920-8642.2023.067

Abstract

Abstract:

BACKGROUND: Community-acquired bloodstream infections (CABSIs) are common in the emergency departments, and some progress to sepsis and even lead to death. However, limited information is available regarding the prediction of patients with high risk of death.
METHODS: The Emergency Bloodstream Infection Score (EBS) for CABSIs was developed to visualize the output of a logistic regression model and was validated by the area under the curve (AUC). The Mortality in Emergency Department Sepsis (MEDS), Pitt Bacteremia Score (PBS), Sequential Organ Failure Assessment (SOFA), quick Sequential Organ Failure Assessment (qSOFA), Charlson Comorbidity Index (CCI), and McCabe-Jackson Comorbid Classification (MJCC) for patients with CABSIs were computed to compare them with EBS in terms of the AUC and decision curve analysis (DCA). The net reclassification improvement (NRI) index and integrated discrimination improvement (IDI) index were compared between the SOFA and EBS.
RESULTS: A total of 547 patients with CABSIs were included. The AUC (0.853) of the EBS was larger than those of the MEDS, PBS, SOFA, and qSOFA (all P<0.001). The NRI index of EBS in predicting the in-hospital mortality of CABSIs patients was 0.368 (P=0.04), and the IDI index was 0.079 (P=0.03). DCA showed that when the threshold probability was < 0.1, the net benefit of the EBS model was higher than those of the other models.
CONCLUSION: The EBS prognostic models were better than the SOFA, qSOFA, MEDS, and PBS models in predicting the in-hospital mortality of patients with CABSIs.

Key words: Community-acquired bloodstream infection, Risk factors, In-hospital mortality, Emergency department

Xinlei Wang, Yao Sun, Xiaoyu Ni, Shu Zhang. Development and validation of an emergency bloodstream infection score for predicting in-hospital mortality in patients with community-acquired bloodstream infections[J]. World Journal of Emergency Medicine, 2023, 14(4): 280-286.

Figures/Tables 5

Table 1.

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Table 4.

Figure 1.

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Variables	Modeling group (n=440)	Validation group (n=107)	P-value
Age, year	57.13±18.63	54.25±17.81	0.149
Sex, male, n (%)	270 (61.40)	65 (60.70)	0.907
Vital signs
Temperature, °C	38.53±1.18	38.39±1.38	0.338
Heart rate, beats/min	115.85±23.39	116.52±29.17	0.826
Respiratory rate, breaths/min	25 (21-30)	24 (20-30)	0.852
Systolic pressure, mmHg	94.51±16.70	93.86±20.46	0.761
Diastolic pressure, mmHg	56.51±13.34	56.30±15.59	0.899
Oxygen saturation, %	95 (93-97)	96 (93-98)	0.263
Highest blood sugar, mmol/L	8.88 (6.77-14.06)	8.33 (6.70-12.50)	0.306
Laboratory results
White blood cell, 10⁹/L	11.56 (7.06-16.26)	10.61 (6.20-14.89)	0.264
Lymphocyte, 10⁹/L	0.66 (0.37-1.07)	0.56 (0.33-1.06)	0.275
Neutrophile granulocyte, 10⁹/L	10.57±6.75	9.39±6.05	0.098
Direct bilirubin, µmol/L	9.10 (5.10-21.08)	10.50 (5.70-32.7)	0.148
AST, U/L	41.50 (22.00-93.75)	49.00 (25.00-109.00)	0.163
Albumin, g/L	32.97±7.10	33.80±7.36	0.233
Globulin, g/L	32.34±7.52	32.19±8.44	0.861
Urea nitrogen, mmol/L	6.79 (4.71-10.84)	6.40 (4.60-10.30)	0.503
Creatinine, µmol/L	90.5 (67.0-131.0)	88 (67-125)	0.700
Cystatin-C, mg/L	1.16 (0.90-1.69)	1.07 (0.89-1.60)	0.311
Creatine kinase, U/L	70.50 (40.00-197.75)	76.00 (45.00-279.00)	0.382
Lactic dehydrogenase, U/L	243.00 (194.00-329.75)	250.00 (191.00-343.00)	0.689
β-HBA, mmol/L	0.25 (0.12-0.63)	0.23 (0.13-0.47)	0.450
INR	1.18 (1.07-1.32)	1.24 (1.08-1.43)	0.028
D-dimer, mg/L	4.61 (2.23-9.40)	7.26 (1.89-9.86)	0.394
PCT, µg/L	12.44 (1.81-48.05)	11.14 (1.30-31.69)	0.345
Infection source, n (%)
Lower respiratory tract	101 (22.95)	26 (24.30)	0.768
Abdominal and gastrointestinal tract	161 (36.59)	47 (43.93)	0.161
Other	178 (45.45)	34 (31.78)	0.099
In-hospital mortality, n (%)	54 (12.27)	18 (16.82)	0.212

Variables	OR (95% CI )	P-value	Regression coefficient	Score
Onset time, d		0.037
≤1	1.000			0
(1,5]	2.675 (1.026-6.977)	0.044	0.984	3
(5,10]	1.434 (0.477-4.309)	0.521	0.360	1
>10	3.909 (1.406-10.869)	0.009	1.363	4
Respiratory rate, breaths/min		<0.001
(0,23]	1.000			0
(23,25]	1.646 (0.424-6.399)	0.472	0.498	1
(25,30]	3.373 (1.178-9.655)	0.024	1.216	3
>30	8.383 (3.066-22.924)	<0.001	2.126	6
Altered mental status	5.866 (2.842-12.108)	<0.001	1.769	5
Lower respiratory tract infection	4.035 (1.972-8.259)	<0.001	1.395	4

Models	AUC	95% CI	P-value	P-value vs. EBS
EBS	0.853	0.769-0.937	<0.001
EBS+CCI	0.869	0.786-0.951	<0.001	0.601
EBS+MJCC	0.871	0.796-0.947	<0.001	0.066
SOFA	0.848	0.759-0.937	<0.001	0.841
qSOFA	0.779	0.670-0.888	<0.001	0.099
PBS	0.782	0.688-0.876	<0.001	0.225
MEDS	0.790	0.689-0.892	<0.001	0.605
CCI	0.667	0.528-0.806	0.026	0.019
MJCC	0.687	0.538-0.835	0.013	0.059

Models	Cutoff	Sensitivity	Specificity
EBS	9.5	0.722	0.820
EBS+CCI	10.5	0.889	0.730
EBS+MJCC	8.5	0.889	0.674
SOFA	7.5	0.857	0.848
qSOFA	1.5	0.786	0.519
PBS	1.5	0.893	0.456
MEDS	9.5	0.786	0.620
CCI	3.5	0.389	0.876
MJCC	1.5	0.556	0.225

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