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Steroids, APACHE II score, and the outcome of abdominal infection
J M Bohnen1, R A Mustard, B D Schouten
1Department of Surgery, University of Toronto, Ontario.
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 II 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.