A stratification strategy to predict secondary infection in critical illness-induced immune dysfunction: the REALIST score
Jan-Alexis Tremblay, Florian Peron, Louis Kreitmann, Julien Textoris, Karen Brengel‐Pesce, Anne‐Claire Lukaszewicz, Laurence Quéméneur, Christophe Védrine, Lionel Tan, Fabienne Venet, Thomas Rimmelé, Guillaume Monneret, Sophie Arnal, Caroline Augris-Mathieu, Frédérique Bayle, Liana Caruso, Charles-Eric Ber, Asma Ben-amor, Anne-Sophie Bellocq, Farida Benatir, Anne Bertin-Maghit, Anne Bertin-Maghit, André Boibieux, Yves Bouffard, Jean-Christophe Cejka, Valérie Cerro, Jullien Crozon-Clauzel, Julien Davidson, Sophie Debord-Peguet, Benjamin Delwarde, Robert Deleat-Besson, Claire Delsuc, Bertrand Devigne, Laure Fayolle-Pivot, Alexandre Faure, Bernard Floccard, Julie Gatel, Charline Genin, Thibaut Girardot, Arnaud Gregoire, Baptiste Hengy, Laetitia Huriaux, Catherine Jadaud, Alain Lepape, Véronique Leray, Anne-Claire Lukaszewicz, Guillaume Marcotte, Olivier Martin, Marie Matray, Delphine Maucort-Boulch, Pascal Meuret, Céline Monard, Florent Moriceau, Guillaume Monneret, Nathalie Panel, Najia Rahali, Thomas Rimmele, Cyrille Truc, Thomas Uberti, Hélène Vallin, Fabienne Venet, Sylvie Tissot, Abbès Zadam, Sophie Blein, Karen Brengel-Pesce, Elisabeth Cerrato, Valerie Cheynet, Emmanuelle Gallet-Gorius, Audrey Guichard, Camille Jourdan, Natacha Koenig, François Mallet, Boris Meunier, Virginie Moucadel, Marine Mommert, Guy Oriol, Alexandre Pachot, Estelle Peronnet, Claire Schrevel, Olivier Tabone, Julien Textoris, Javier Yugueros Marcos, Jeremie Becker, Frederic Bequet, Yacine Bounab, Florian Brajon, Bertrand Canard, Muriel Collus, Nathalie Garcon, Irene Gorse, Cyril Guyard, Fabien Lavocat, Philippe Leissner, Karen Louis, Maxime Mistretta, Jeanne Moriniere, Yoann Mouscaz, Laura Noailles, Magali Perret, Frederic Reynier
Abstract
BACKGROUND: Although multiple individual immune parameters have been demonstrated to predict the occurrence of secondary infection after critical illness, significant questions remain with regards to the selection, timing and clinical utility of such immune monitoring tests. RESEARCH QUESTION: As a sub-study of the REALISM study, the REALIST score was developed as a pragmatic approach to help clinicians better identify and stratify patients at high risk for secondary infection, using a simple set of relatively available and technically robust biomarkers. STUDY DESIGN AND METHODS: This is a sub-study of a single-centre prospective cohort study of immune profiling in critically ill adults admitted after severe trauma, major surgery or sepsis/septic shock. For the REALIST score, five immune parameters were pre-emptively selected based on their clinical applicability and technical robustness. Predictive power of different parameters and combinations of parameters was assessed. The main outcome of interest was the occurrence of secondary infection within 30 days. RESULTS: ) neutrophils and serum IL-10 level. In the cohort of interest (n = 189), incidence of secondary infection at day 30 increased from 8% for patients with REALIST score of 0 to 46% in patients with a score of 3 abnormal parameters, measured ad D5-7. When adjusted for a priori identified clinical risk factors for secondary infection (SOFA score and invasive mechanical ventilation at D5-7), a higher REALIST score was independently associated with increased risk of secondary infection (42 events (22.2%), adjusted HR 3.22 (1.09-9.50), p = 0.034) and mortality (10 events (5.3%), p = 0.001). INTERPRETATION: We derived and presented the REALIST score, a simple and pragmatic stratification strategy which provides clinicians with a clear assessment of the immune status of their patients. This new tool could help optimize care of these individuals and could contribute in designing future trials of immune stimulation strategies.