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June - 2018

   

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Association of the Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Score With Excess Hospital Mortality in Adults With Suspected Infection in Low- and Middle-Income Countries

K Rudd, C Seymour, A Aluisio, et al for the Sepsis Assessment and Identification in Low Resource Settings (SAILORS) Collaboration JAMA, 2018, 319(21):2202-2211

Comment

In 2016, sepsis was redefined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. In addition, members of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) task force proposed qSOFA (quick Sequential [Sepsis-related] Organ Failure Assessment)—a score using simple clinical criteria—to assist bedside clinicians to identify patients with sepsis, or likely to develop it.

The final qSOFA model included 3 parameters: 

1. GCS < 15 (1 point)

2. SBP < 100 mm Hg (1 point)

3. RR > 22/min (1 point)

Since then we have learnt that qSOFA performed well for prediction of mortality in patients presenting to ED with suspected infection  https://www.crit-iq.com/index.php/Library/Review/1285/sepsis-qsofa-consensus-severity-intensive-care-critical-mortality-sofa-validity-SIRS , but does not perform as well as SOFA score in the ICU for prediction of hospital mortality in severe sepsis.  https://www.crit-iq.com/index.php/Library/Review/1284/sepsis-qsofa-consensus-severity-intensive-care-critical-mortality-sofa-validity-SIRS

We know that conservatively their are 6 million deaths from sepsis each year. We also know that 87% of the world population live in low- and middle-income countries (LMICs), with no data on the mortality from sepsis  https://www.crit-iq.com/index.php/Library/Review/1328/sepsis-intensive-critical-intensive-global-outcomes-WHO-clinical-public-health What about the performance of qSOFA at predicting excess hospital mortality in patients with suspected infection in ?

In this retrospective secondary analysis of 9 diverse (LMIC) cohorts (Bangladesh, Haiti, India, Indonesia,Myanmar,Rwanda, Sierra Leone, Sri Lanka, Thailand, and Vietnam);

  • 6569 hospitalized adults with suspected infection
  • HIV prevalence ranged from 2-47%, there was heterogeneity in infection type, and overall hospital mortality was 1-39%
  • The distribution of qSOFA 0-3, and 0-4 SIRS criteria are provided
  • Mental status was the most frequently missing qSOFA component, and WCC most frequently missing SIRS component. 
  • The proportion of patients who died consistently increased with higher qSOFA score (3%, 8%, 16%, 30% for score 0,1,2,3) but not SIRS (5%, 11%, 13%, 13%, 12% for 0,1,2,3,4 criteria).
  • Amongst those with known vita status at hospital discharge, the 35% with qSOFA 2 or 3 accounted for 62% of deaths, while 47% with 2 or more SIRS accounted for 59% of deaths.
  • Overall the OR for hospital mortality comparing patients with high vs low or moderate score was higher for qSOFA than for SIRS overall 
  • There was a stepwise increase in the odds of hospital mortality comparing moderate (1) vs low(0), and high (≥2) vs low (0), qSOFA score in the combined cohort. These incremental changes were less apparent for SIRS criteria. For example, the OR for hospital mortality;
    • Moderate vs low: OR 2.8 for qSOFA (hospital mortality, 8%vs 3%), compared with 2.5 for SIRS criteria (hospital mortality 11% vs 5%)
    • High vs low: OR 7.2 for qSOFA (hospital mortality 19% vs 3%), OR 3.3 for SIRS(20%vs 7%)

Overall in LMICs, a qSOFA score greater than or equal to 2 was significantly associated with increased likelihood of excess hospital death compared with a lower score (odds ratio, 3.6). In addition, the qSOFA performed well across a range of countries and infective conditions (malaria, dengue fever, viral haemorrhagic infection) The qSOFA performed better at predicting death. This is important, as the qSOFA does not require lab testing like SIRS, a crucial consideration in resource limited countries. 

The accompanying editorial points out the potential use, and limits of this information. qSOFA was not intended to diagnose sepsis, but can it help with clinical direction? Will a low score indicate who can go home, a high score who needs intervetnion with scare critical care resources? OR will they be used for prognostic enrichment in trials? Ultimately, can qSOFA provide a tooll to help improve outcomes.

 

Abstract

Importance  The quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score has not been well-evaluated in low- and middle-income countries (LMICs).

Objective  To assess the association of qSOFA with excess hospital death among patients with suspected infection in LMICs and to compare qSOFA with the systemic inflammatory response syndrome (SIRS) criteria.

Design, Settings, and Participants  Retrospective secondary analysis of 8 cohort studies and 1 randomized clinical trial from 2003 to 2017. This study included 6569 hospitalized adults with suspected infection in emergency departments, inpatient wards, and intensive care units of 17 hospitals in 10 LMICs across sub-Saharan Africa, Asia, and the Americas.

Exposures  Low (0), moderate (1), or high (≥2) qSOFA score (range, 0 [best] to 3 [worst]) or SIRS criteria (range, 0 [best] to 4 [worst]) within 24 hours of presentation to study hospital.

Main Outcomes and Measures  Predictive validity (measured as incremental hospital mortality beyond that predicted by baseline risk factors, as a marker of sepsis or analogous severe infectious course) of the qSOFA score (primary) and SIRS criteria (secondary).

Results  The cohorts were diverse in enrollment criteria, demographics (median ages, 29-54 years; males range, 36%-76%), HIV prevalence (range, 2%-43%), cause of infection, and hospital mortality (range, 1%-39%). Among 6218 patients with nonmissing outcome status in the combined cohort, 643 (10%) died. Compared with a low or moderate score, a high qSOFA score was associated with increased risk of death overall (19% vs 6%; difference, 13% [95% CI, 11%-14%]; odds ratio, 3.6 [95% CI, 3.0-4.2]) and across cohorts (P < .05 for 8 of 9 cohorts). Compared with a low qSOFA score, a moderate qSOFA score was also associated with increased risk of death overall (8% vs 3%; difference, 5% [95% CI, 4%-6%]; odds ratio, 2.8 [95% CI, 2.0-3.9]), but not in every cohort (P < .05 in 2 of 7 cohorts). High, vs low or moderate, SIRS criteria were associated with a smaller increase in risk of death overall (13% vs 8%; difference, 5% [95% CI, 3%-6%]; odds ratio, 1.7 [95% CI, 1.4-2.0]) and across cohorts (P < .05 for 4 of 9 cohorts). qSOFA discrimination (area under the receiver operating characteristic curve [AUROC], 0.70 [95% CI, 0.68-0.72]) was superior to that of both the baseline model (AUROC, 0.56 [95% CI, 0.53-0.58; P < .001) and SIRS (AUROC, 0.59 [95% CI, 0.57-0.62]; P < .001).

Conclusions and Relevance  When assessed among hospitalized adults with suspected infection in 9 LMIC cohorts, the qSOFA score identified infected patients at risk of death beyond that explained by baseline factors. However, the predictive validity varied among cohorts and settings, and further research is needed to better understand potential generalizability.

June


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