STEROIDS, APACHE-II SCORE, AND THE OUTCOME OF ABDOMINAL INFECTION

Objective: To compare the outcome of abdominal infection in patients w ith or without previous systemic glucocorticoid therapy and to determi ne the effect of steroid administration on the relationship between AP ACHE II (Acute Physiology and Chronic Health Evaluation) scores and mo rtality. Hypothesis: Steroid therapy leads to greater mortality and re latively lower APACHE II scores. Design: Prospective cohort study. Set ting: University hospital. Patients: Two hundred ninety-seven consecut ive adult patients with abdominal infection treated by surgical or per cutaneous drainage. Treatment was at the clinician's discretion. Seven ty-one patients received systemic steroid therapy. Outcome Measures: A PACHE II score, clinical course, and death in hospital; relationship b etween APACHE II score and mortality in the steroid and no steroid gro ups. Results: Thirty-three patients receiving steroid therapy (46%) di ed vs 55 (24%) of 226 patients not receiving steroid therapy. The APAC HE II score (P<.0001) and steroid administration (P=.04) were each ind ependently associated with death. Steroid-treated patients had the sam e probability of dying as ''nonsteroid'' patients with an APACHE II sc ore 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 appropri ate correction for steroid-treated patients is 80%, 60%, or 40%, respe ctively. Conclusions: Patients receiving steroid therapy appear to be at higher risk of dying of abdominal infection than predicted by APACH E 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 APACH E II points.