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Early application of generic mortality risk scores in presumed meningococcal disease
Marino S Festa1, Shane M Tibby, Dan Taylor
1Guys & St. Thomas Hospital, London, United Kingdom.
Insights
Two pediatric mortality risk scores, Pre-ICU PRISM and PIM, effectively identify children with meningococcal disease at high risk for poor outcomes. While both scores aid clinical trial stratification, PIM offers simpler data collection for assessing pediatric sepsis severity.
Area of Science:
- Pediatric critical care medicine
- Infectious disease epidemiology
- Clinical risk prediction modeling
Background:
- Meningococcal disease poses a significant mortality risk, often within 24 hours of pediatric intensive care unit (ICU) admission.
- Accurate early mortality risk assessment is crucial for designing clinical trials of novel therapeutic interventions.
Purpose of the Study:
- To evaluate the performance of two established pediatric mortality risk scores, the Pre-ICU PRISM and PIM, in predicting outcomes for children with meningococcal disease.
- To assess the utility of these scores for stratifying patients in clinical trials.
Main Methods:
- A prospective, observational study was conducted over 21 months in two tertiary pediatric ICUs in southeast England.
- 165 consecutive children diagnosed with meningococcal disease were included, with ages ranging from 0.1 to 17 years.
- The performance of the Pre-ICU PRISM and PIM scores was assessed for their ability to discriminate and calibrate mortality risk within 1 hour of ICU admission.
Main Results:
- The Pediatric Index of Mortality (PIM) demonstrated superior data completeness (93%) compared to the Pre-ICU PRISM (35%).
- Both scores exhibited good discrimination, with areas under the receiver operating characteristic curve of 0.90 for PIM and 0.94 for Pre-ICU PRISM.
- Calibration was poor for both scores, with an overestimation of mortality in medium-risk strata.
Conclusions:
- The Pre-ICU PRISM and PIM scores effectively discriminate mortality risk in pediatric meningococcal sepsis but exhibit poor calibration.
- Both scores are valuable for patient stratification in clinical trials for meningococcal disease.
- The PIM score offers a practical advantage due to its ease of data collection.
Objective:
Mortality from meningococcal disease typically occurs within 24 hrs of intensive care unit (ICU) admission. An early, accurate mortality-risk tool may aid in trial design for novel therapies. We assessed the performance of two generic scores that assign mortality risk within 1 hr of ICU admission: the Preintensive Care Pediatric Risk of Mortality (Pre-ICU PRISM) and Pediatric Index of Mortality (PIM).
Design:
Prospective, observational study over 21 months.
Setting:
Two tertiary pediatric ICUs accepting referrals from southeast England.
Patients:
Patients were 165 consecutive children with meningococcal disease. Ages ranged from 0.1 to 17 yrs (median 2.3 yrs).
Interventions:
None.
Measurements And Main Results:
PIM demonstrated greater sensibility, with complete data collected in 93% of cases, compared with 35% for the pre-ICU PRISM. Both scores discriminated well. The area under the receiver operating characteristic curve was 0.90 (95% confidence interval, 0.81-1.00) for PIM and 0.94 (95% confidence interval, 0.88-0.98) for Pre-ICU PRISM; this did not change when applied to the subgroup of patients with complete data. Both scores calibrated poorly, overestimating mortality in the medium-risk strata (and also in the high-risk stratum in the case of Pre-ICU PRISM). When used as a stratification tool for a hypothetical trial (60% reduction in mortality, 80% power), the scores allowed for a reduction in study size by 50% (PIM) and 43% (pre-ICU PRISM).
Conclusions:
Pre-ICU PRISM and PIM both discriminate well but calibrate poorly when applied to a cohort of children with meningococcal sepsis. Both scores provide an effective means of stratification for clinical trial purposes. The main advantage for PIM appears to be ease of data collection.
