National Early Warning Score (NEWS) and Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Validation in AML Patient during Febrile Neutropenia

Acute mieloid leukemia (AML) patients are at high risk of infections during the neutropenia period post chemotherapy. Fever often is the first sign of a deterioration of the patient. Better outcomes are reached with early diagnosis and prompt interventions, but nowadays there are not satisfactory diagnostic tools. Recently the quick Sequential (Sepsis Related) Organ Failure Assessment (qSOFA) was proven predicting out-Intensive Care Unit (ICU) mortality in a large cohort of miscellaneous patients. Also the National Early Warning Score (NEWS) was proposed predicting in hospital mortality. qSOFA score consists of three parameters, each of wich are allocated with one point: respiration rate > or = 22/min, systolic blood pressure < or = 100 mmHg and altered mental status. NEWS instead is a warning score that evaluates seven clinical parameters, each of wich are allocated with 0-3 points.

The aim of our study was to assess the validation of the NEWS and the qSOFA in a homogeneous cohort of AML patients during the neutropenic fever period.

All patients underwent chemotherapy in induction course and cases with complete remission continued the therapy with consolidation cycles. For each patient data about age, infections, antimicrobical therapy, coltures were collected. Furthermore for each fever day during aplasia period aggregate score of NEWS e qSOFA were calculated. In addition data on clinical deterioration like SIRS criteria, amine necessity, respiratory failure, ventilation support, ICU admission and death were analyzed. The ability of the NEWS and the qSOFA score on prediction of the clinical deterioration was analyzed by calculating the area under the curve (AUROC) using the logistic regression model.

A total of 334 consecutive patients were evaluated; the median age was 53 years old. After induction course a complete remission was achieved in 238 patients (71%), 74 were resistant (22%) and 22 died (7%). 112 patients (34%) underwent allogeneic stem cell transplantation. A total of 2792 neutropenic fever days were analyzed. There was a significant difference between the NEWS evaluated in the first day of fever in Gram negative bacteriemia (median NEWS = 2) respect on Gram positive one (median NEWS =1) (p=0.0006). also qSOFA was higher in the Gram negative bacteriemia (p=0.004). Both NEWS and qSOFA were able to predict faithfully different outcomes of clinical deterioration in the same day of the evaluation of the scores: for example the NEWS AUROC for the use of amine was 0.899 and the qSOFA AUROC was 0.868; the NEWS AUROC for the ICU admission was 0.917 and the qSOFA AUROC was 0.916; lastly NEWS AUROC for the death was 0.984 and qSOFA AUROC 0.969. The two scores were able to predict these outcomes also 24 hours after the scores determination in lag-1 analysis: the NEWS AUROC for the use of amine was 0.885 and the qSOFA AUROC was 0.837; the NEWS AUROC for the ICU admission was 0.933 and the qSOFA AUROC was 0.910; lastly NEWS AUROC for the death was 0.924 and qSOFA AUROC 0.884. Besides in the lag-2 analysis (48 hours after the score determination) NEWS and qSOFA score were accurate to predict outcomes: the NEWS AUROC for the use of amine was 0.837 and the qSOFA AUROC was 0.772; the NEWS AUROC for the ICU admission was 0.888 and the qSOFA AUROC was 0.830; lastly NEWS AUROC for the death was 0.894 and qSOFA AUROC 0.827.

Actually this analysis is the first validation of the NEWS and the qSOFA in a large AML patients cohort during neutropenic fever. So NEWS as qSOFA may be considered valid tools to evaluate critical hematologic patients in intensive chemoterapy induced aplasia.