Comparison of PIRO, SOFA, and MEDS Scores for Predicting Mortality in Emergency Department Patients With Severe Sepsis and Septic Shock

Abstract

Objectives: The Predisposition Insult Response and Organ failure (PIRO) scoring system has been developed for use in the emergency department (ED) to risk stratify sepsis cases, but has not been well studied among high-risk patients with severe sepsis and septic shock. The PIRO score was compared with the Sequential Organ Failure Assessment (SOFA) and Mortality in ED Sepsis (MEDS) scores to predict mortality in ED patients with features suggesting severe sepsis or septic shock in the ED. Methods:This was an analysis of sepsis patients enrolled in a prospective observational ED study of patients presenting with evidence of shock, hypoxemia, or other organ failure. PIRO, MEDS, and SOFA scores were calculated from ED data. Analysis compared areas under the receiver operator characteristic (ROC) curves for 30-day mortality.Results: Of 240 enrolled patients, final diagnoses were septic shock in 128 (53%), severe sepsis without shock in 70 (29%), and infection with no organ dysfunction in 42 (18%). Forty-eight (20%) patients died within 30 days of presentation. Area under the ROC curve (AUC) for mortality was 0.86 (95% confidence interval [CI] = 0.80 to 0.92) for PIRO, 0.81 (95% CI = 0.74 to 0.88) for MEDS, and 0.78 (95% CI = 0.71 to 0.87) for SOFA scores. Pairwise comparisons of the AUC were as follows: PIRO versus SOFA, p = 0.01; PIRO versus MEDS, p = 0.064; and MEDS versus SOFA; p = 0.37. Mortality increased with increasing PIRO scores: PIRO < 5, 0%; PIRO 5 to 9, 5%; PIRO 10 to 14, 5%; PIRO 15 to 19, 37%; and PIRO ≥ 20, 80% (p < 0.001). The MEDS score also showed increasing mortality with higher scores: MEDS < 5, 0%; MEDS 5 to 7, 12%; MEDS 8 to 11, 15%; MEDS 12 to 14, 48%; and MEDS > 15, 65% (p < 0.001).Conclusions: The PIRO model, taking into account comorbidities and septic source as well as physiologic status, performed better than the SOFA score and similarly to the MEDS score for predicting mortality in ED patients with severe sepsis and septic shock. These findings have implications for identifying and managing high-risk patients and for the design of clinical trials in sepsis.

AME evidence series 001—The Society for Translational Medicine: clinical practice guidelines for diagnosis and early identification of sepsis in the hospital

“…Although some investigators argued that PIRO was only attractive in its conceptual framework (17), recent evidence supported it as an accurate predictor of mortality. The PIRO system indeed outperformed the SOFA score in predicting mortality (AUC: 0.86; 95% CI: 0.80 to 0.92 vs. 0.78; 95% CI: 0.71 to 0.87) of patients with severe sepsis and of septic shock patients in the emergency department (18). However, inferior results were obtained from other studies with AUCs ranging between 0.68 and 0.744, from various emergency department cohorts (18)(19)(20)(21).…”

“…The PIRO system indeed outperformed the SOFA score in predicting mortality (AUC: 0.86; 95% CI: 0.80 to 0.92 vs. 0.78; 95% CI: 0.71 to 0.87) of patients with severe sepsis and of septic shock patients in the emergency department (18). However, inferior results were obtained from other studies with AUCs ranging between 0.68 and 0.744, from various emergency department cohorts (18)(19)(20)(21). To date, no randomized controlled trials (RCT) have explored how patient-important outcomes (e.g., mortality, long term physical and cognitive behavior, return to previously normal function etc.)…”

Association of tumor necrosis factor α −308G/A and interleukin-6 −174G/C gene polymorphism with pneumonia-induced sepsis

“…However, the outcome is still unclear for patients and health providers [1,2]. The systemic immune system reaction plays a major role in septic shock pathogenesis [3]. When local pneumonia develops into widely systemic sepsis, many infection defense factors are activated.…”

Prognostic value of CD4+CD25+ Tregs as a valuable biomarker for patients with sepsis in ICU

“…[8] Therefore, it is pivotal to accurately predict prognosis of sepsis patients at different stages and to help optimize treatment options. There are few well-established scoring tools including APACHE II score, improved early warning score (modified early warning score, MEWS), and SOFA score, [9] which have been useful in predicting clinical outcomes. However, it is believed that more effort is needed to fi nd predictive biomarkers at earlier stages such as early changes in immune status in sepsis patients, because immune response has been one of the key factors for the pathogenesis of sepsis.…”