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Vol. 45. Issue 8.
Pages 459-469 (November 2021)
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Vol. 45. Issue 8.
Pages 459-469 (November 2021)
Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department
Validación del sistema PIRO (predisposición, infección, respuesta, fallo orgánico) para la estratificación del pronóstico en pacientes con sepsis en el servicio de urgencias
V. Caramelloa,
Corresponding author

Corresponding author.
, A. Macciottab, V. Beuxd, A.V. De Salvea, F. Riccerib,c, A. Boccuzzia
a Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
b Department of Clinical and Biological Science, University of Turin, Orbassano, TO, Italy
c Unit of Epidemiology, Regional Health Service ASL TO3, Grugliasco, TO, Italy
d University of Turin, Italy
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Tables (3)
Table 1. Variables and points assigned to each variable for the three PIRO methods PIRO 1,3,13,26,27,29 PIRO24,5,28 and PIRO3.2 P, PREDISPOSITION; I, INFECTION; R, RESPONSE; O, ORGAN FAILURE; CLD, chronic liver disease; COPD, Chronic Obstructive pulmonary disease; NH, nursing home; CA, community-acquired; UTI, urinary tract infection; RR, respiratory rate; HR, heart rate; CNS, central nervous system; UO, urine output; OF, organ failure; SBP, Systolic blood pressure; BUN, blood urea nitrogen; GCS, Glasgow coma scale; PT, prothrombin time; INR, International normalized ratio; PaO2, arterial oxygen partial pressure; FiO2, fractional inspired oxygen.
Table 2. Detailed results of clinical scores, frequencies of patients (and percentages in brackets) with predisposing factors, frequencies of patients with infection in different sites and by different pathogens, means and standard deviation or median and interquartile ranges for age and response variables.
Table 3. Description of number of patients (percentage in brackets) for each outcome in study. Discharged patients, admitted patients in general ward and in high-intensity-of-care wards (namely High Dependency Unit HDU and Intensive Care Unit ICU) and mortality in the hospital (H) and out of hospital are detailed separately for short and medium-term follow up (30 and 60 days).
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There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital.

Design, setting and participants

We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA.


Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716–0.824) vs. AUC 0.699 (0.64–0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715–0.819) vs AUC 0.709 (0.656–0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71–0.82) at 30 d, AUC 0.754 (0.701–0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA.


We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.

PIRO score
ICU admission
Prognostic stratification
Staging system

Existen muchos métodos diferentes para calcular la escala PIRO (predisposición, infección respuesta, fallo orgánico). Comparamos 3 métodos (PIRO1 [Howell], PIRO2 [Rubolotta] y PIRO3 [Rathour]) para estratificar la mortalidad y el ingreso con alto nivel de cuidados en pacientes con sepsis atendidos en el servicio de urgencias (SU) de un hospital italiano.

Diseño, entorno y participantes

Recopilamos datos clínicos prospectivos de 470 pacientes que llegaban con una infección al SU, con el fin de calcular la puntuación PIRO, de acuerdo con 3 métodos diferentes. Evaluamos las variables PIRO para la predicción de la mortalidad en un análisis monovariable. Calculamos y comparamos el área bajo la curva (AUC) característica de operación del receptor (ROC) de los 3 métodos PIRO, SOFA y qSOFA.


La mayoría de las variables incluidas en las puntuaciones PIRO estaban relacionadas con la mortalidad en un análisis de una sola variable. El aumento de la puntuación PIRO se relacionó con una mortalidad más elevada. En cuanto a la mortalidad, PIRO1 presentó un rendimiento mejor que PIRO2 a los 30 días (AUC 0,77 [0,716-0,824] frente a AUC 0,699 [0,64-0,758]; p=0,03) y similares a los 60 días (AUC 0,767 [0,715-0,819] frente a AUC 0,709 [0,656-0,763]; p=0,55); PIRO1 presentó un rendimiento similar al de PIRO3 (AUC 0,765 [0,71-0,82] a los 30 días, AUC 0,754 [0,701-0,806] a los 60 días; p=NS). Tanto PIRO1 como PIRO3 presentaron un rendimiento similar al de SOFA para la mortalidad (AUC 0,758 [0,699-0,816) al cabo de 30 días y AUC 0,738 [0,681-0,795] al cabo de 60 días; p=NS). En cuanto al ingreso con alto nivel de cuidados, las puntuaciones PIRO resultaron ser inferiores a SOFA.


Apoyamos el uso de la puntuación PIRO1, que resulta fácil de usar, y presenta el mejor rendimiento en cuanto a la mortalidad a largo plazo. PIRO2 resultó ser menos precisa y más compleja de usar, y se vio afectada por problemas de falta de datos microbiológicos en el entorno del SU.

Palabras clave:
Puntuación PIRO
Ingreso en UCI
Estratificación pronóstica
Sistema de estadificación


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