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Steroids, APACHE II Score, and the Outcome of Abdominal Infection

Steroids, APACHE II Score, and the Outcome of Abdominal Infection Abstract Objective: To compare the outcome of abdominal infection in patients with or without previous systemic glucocorticoid therapy and to determine the effect of steroid administration on the relationship between APACHE II (Acute Physiology and Chronic Health Evaluation) scores and mortality. Hypothesis: Steroid therapy leads to greater mortality and relatively lower APACHE II scores. Design: Prospective cohort study. Setting: University hospital. Patients: Two hundred ninety-seven consecutive adult patients with abdominal infection treated by surgical or percutaneous drainage. Treatment was at the clinician's discretion. Seventy-one patients received systemic steroid therapy. Outcome Measures: APACHE II score, clinical course, and death in hospital; relationship between APACHE II score and mortality in the steroid and no steroid groups. Results: Thirty-three patients receiving steroid therapy (46%) died vs 55 (24%) of 226 patients not receiving steroid therapy. The APACHE II score (P<.0001) and steroid administration (P=.04) were each independently associated with death. Steroid-treated patients had the same probability of dying as "nonsteroid" patients with an APACHE II score a mean of 3.7 points higher (95% confidence limits, 0.03 and 7.7). The confidence that 2, 3, or 4 extra APACHE II points is the appropriate correction for steroid-treated patients is 80%, 60%, or 40%, respectively. Conclusions: Patients receiving steroid therapy appear to be at higher risk of dying of abdominal infection than predicted by APACHE 11 scores. The number of patients receiving cancer chemotherapy was too small to determine whether this was an additional risk factor. In the design of clinical trials stratified by APACHE II scores, steroid-treated patients should either be excluded or assigned two extra APACHE II points.(Arch Surg. 1994;129:33-38) References 1. Solomkin JS, Dellinger EP, Christou NV, Mason AD. Design and conduct of antibiotic trials: a report of the Scientific Studies Committee of the Surgical Infection Society . Arch Surg . 1987;122:158-164.Crossref 2. Nystrom P-O, Bax R, Dellinger EP, et al. Proposed definitions for diagnosis, severity scoring, stratification, and outcome for trials on intra-abdominal infection . World J Surg . 1990;14:148-158.Crossref 3. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system . Crit Care Med . 1985;13:818-829.Crossref 4. Bohnen JMA, Mustard RA, Oxholm SE, Schouten BD. APACHE II score and abdominal sepsis: a prospective study . Arch Surg . 1988;123:225-229.Crossref 5. Efron B, Tibshirani R. Bootstrap methods for standard errors, confidence intervals, and other measures of statistical accuracy . Stat Sci . 1986;1:54-77.Crossref 6. DeMaria EJ, Reichman W, Kenney PR, Armitage JM, Gann DS. Septic complications of corticosteroid administration after central nervous system trauma . Ann Surg . 1985;202:248-252.Crossref 7. Dayton MT, Kleckner SC, Brown DK. Peptic ulcer perforation associated with steroid use . Arch Surg . 1987;122:376-380.Crossref 8. Rubin RH, Cosimi AB. Infection in the immunocompromised host . In: Howard RJ, Simmons RL, eds. Surgical Infectious Diseases . 2nd ed. East Norwalk, Conn: Appleton & Lange: 1988;849-872. 9. Reding R, Michel LA, Donckier J, de Canniere L, Jamart J. Surgery in patients on long-term steroid therapy: a tentative model for risk assessment . Br J Surg . 1990;77:1175-1178.Crossref 10. Schumer W. Steroids in the treatment of clinical septic shock . Ann Surg . 1976; 184:333-340.Crossref 11. Sleeman HK, Diggs JW, Hayes DK, Hamit HF. Value of antibiotics, corticosteroids, and peritoneal lavage in the treatment of experimental peritonitis . Surgery . 1969;66:1060-1066. 12. Bone RC, Fisher CJ, Clemmer TP, Slotman GJ, Metz CA, Balk RA. A controlled trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock . N Engl J Med . 1987;317:653-658.Crossref 13. Veterans Administration Systemic Sepsis Cooperative Study Group. Effect of high-dose glucocorticoid therapy on mortality in patients with clinical signs of systemic sepsis . N Engl J Med . 1987;317:659-665.Crossref 14. Dawson JL. A study of some factors affecting the mortality rate in diffuse peritonitis . Gut . 1963;4:368-372.Crossref 15. Stephen M, Loewenthal J. Generalized infective peritonitis . Surg Gynecol Obstet . 1978;147:231-234. 16. Elebute EA, Stoner HB. The grading of sepsis . Br J Surg . 1983;70:29-31.Crossref 17. Stevens LE. Gauging the severity of surgical sepsis . Arch Surg . 1983;118: 1190-1192.Crossref 18. Meakins JL, Solomkin JS, Allo MD, Dellinger EP, Howard RJ, Simmons RL. A proposed classification of intra-abdominal infections: stratification of etiology and risk for future therapeutic trials . Arch Surg . 1984;119:1372-1378.Crossref 19. Dominioni L, Dionigi R, Zanello M, et al. Sepsis score and acute phase protein response as predictors of outcome in septic surgical patients . Arch Surg . 1987; 122:141-146.Crossref 20. Dellinger EP. Use of scoring systems to assess patients with surgical sepsis . Surg Clin North Am . 1988;68:123-145. 21. Solomkin JS, Dellinger EP, Christou NV, Busuttil RW. Results of a multicenter trial comparing imipenem/cilastatin to tobramycin/clindamycin for intraabdominal infections . Ann Surg . 1990;212:581-591.Crossref 22. Burchard KW. Fungal sepsis . Infect Dis Clin North Am . 1992;6:677-692. 23. Solomkin JS, Flohr AB, Quie PG, Simmons RL. The role of Candida in intraperitoneal infections . Surgery . 1980;88:524-530. 24. Peoples JB. Candida and perforated peptic ulcers . Surgery . 1986;100:758-764. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Steroids, APACHE II Score, and the Outcome of Abdominal Infection

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References (25)

Publisher
American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1994.01420250045005
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: To compare the outcome of abdominal infection in patients with or without previous systemic glucocorticoid therapy and to determine the effect of steroid administration on the relationship between APACHE II (Acute Physiology and Chronic Health Evaluation) scores and mortality. Hypothesis: Steroid therapy leads to greater mortality and relatively lower APACHE II scores. Design: Prospective cohort study. Setting: University hospital. Patients: Two hundred ninety-seven consecutive adult patients with abdominal infection treated by surgical or percutaneous drainage. Treatment was at the clinician's discretion. Seventy-one patients received systemic steroid therapy. Outcome Measures: APACHE II score, clinical course, and death in hospital; relationship between APACHE II score and mortality in the steroid and no steroid groups. Results: Thirty-three patients receiving steroid therapy (46%) died vs 55 (24%) of 226 patients not receiving steroid therapy. The APACHE II score (P<.0001) and steroid administration (P=.04) were each independently associated with death. Steroid-treated patients had the same probability of dying as "nonsteroid" patients with an APACHE II score a mean of 3.7 points higher (95% confidence limits, 0.03 and 7.7). The confidence that 2, 3, or 4 extra APACHE II points is the appropriate correction for steroid-treated patients is 80%, 60%, or 40%, respectively. Conclusions: Patients receiving steroid therapy appear to be at higher risk of dying of abdominal infection than predicted by APACHE 11 scores. The number of patients receiving cancer chemotherapy was too small to determine whether this was an additional risk factor. In the design of clinical trials stratified by APACHE II scores, steroid-treated patients should either be excluded or assigned two extra APACHE II points.(Arch Surg. 1994;129:33-38) References 1. Solomkin JS, Dellinger EP, Christou NV, Mason AD. Design and conduct of antibiotic trials: a report of the Scientific Studies Committee of the Surgical Infection Society . Arch Surg . 1987;122:158-164.Crossref 2. Nystrom P-O, Bax R, Dellinger EP, et al. Proposed definitions for diagnosis, severity scoring, stratification, and outcome for trials on intra-abdominal infection . World J Surg . 1990;14:148-158.Crossref 3. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system . Crit Care Med . 1985;13:818-829.Crossref 4. Bohnen JMA, Mustard RA, Oxholm SE, Schouten BD. APACHE II score and abdominal sepsis: a prospective study . Arch Surg . 1988;123:225-229.Crossref 5. Efron B, Tibshirani R. Bootstrap methods for standard errors, confidence intervals, and other measures of statistical accuracy . Stat Sci . 1986;1:54-77.Crossref 6. DeMaria EJ, Reichman W, Kenney PR, Armitage JM, Gann DS. Septic complications of corticosteroid administration after central nervous system trauma . Ann Surg . 1985;202:248-252.Crossref 7. Dayton MT, Kleckner SC, Brown DK. Peptic ulcer perforation associated with steroid use . Arch Surg . 1987;122:376-380.Crossref 8. Rubin RH, Cosimi AB. Infection in the immunocompromised host . In: Howard RJ, Simmons RL, eds. Surgical Infectious Diseases . 2nd ed. East Norwalk, Conn: Appleton & Lange: 1988;849-872. 9. Reding R, Michel LA, Donckier J, de Canniere L, Jamart J. Surgery in patients on long-term steroid therapy: a tentative model for risk assessment . Br J Surg . 1990;77:1175-1178.Crossref 10. Schumer W. Steroids in the treatment of clinical septic shock . Ann Surg . 1976; 184:333-340.Crossref 11. Sleeman HK, Diggs JW, Hayes DK, Hamit HF. Value of antibiotics, corticosteroids, and peritoneal lavage in the treatment of experimental peritonitis . Surgery . 1969;66:1060-1066. 12. Bone RC, Fisher CJ, Clemmer TP, Slotman GJ, Metz CA, Balk RA. A controlled trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock . N Engl J Med . 1987;317:653-658.Crossref 13. Veterans Administration Systemic Sepsis Cooperative Study Group. Effect of high-dose glucocorticoid therapy on mortality in patients with clinical signs of systemic sepsis . N Engl J Med . 1987;317:659-665.Crossref 14. Dawson JL. A study of some factors affecting the mortality rate in diffuse peritonitis . Gut . 1963;4:368-372.Crossref 15. Stephen M, Loewenthal J. Generalized infective peritonitis . Surg Gynecol Obstet . 1978;147:231-234. 16. Elebute EA, Stoner HB. The grading of sepsis . Br J Surg . 1983;70:29-31.Crossref 17. Stevens LE. Gauging the severity of surgical sepsis . Arch Surg . 1983;118: 1190-1192.Crossref 18. Meakins JL, Solomkin JS, Allo MD, Dellinger EP, Howard RJ, Simmons RL. A proposed classification of intra-abdominal infections: stratification of etiology and risk for future therapeutic trials . Arch Surg . 1984;119:1372-1378.Crossref 19. Dominioni L, Dionigi R, Zanello M, et al. Sepsis score and acute phase protein response as predictors of outcome in septic surgical patients . Arch Surg . 1987; 122:141-146.Crossref 20. Dellinger EP. Use of scoring systems to assess patients with surgical sepsis . Surg Clin North Am . 1988;68:123-145. 21. Solomkin JS, Dellinger EP, Christou NV, Busuttil RW. Results of a multicenter trial comparing imipenem/cilastatin to tobramycin/clindamycin for intraabdominal infections . Ann Surg . 1990;212:581-591.Crossref 22. Burchard KW. Fungal sepsis . Infect Dis Clin North Am . 1992;6:677-692. 23. Solomkin JS, Flohr AB, Quie PG, Simmons RL. The role of Candida in intraperitoneal infections . Surgery . 1980;88:524-530. 24. Peoples JB. Candida and perforated peptic ulcers . Surgery . 1986;100:758-764.

Journal

Archives of SurgeryAmerican Medical Association

Published: Jan 1, 1994

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