Steroids, APACHE II score, and the outcome of abdominal infection
J. M. Bohnen, R. A. Mustard and B. D. Schouten
Department 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.
