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

Abstract

for the Sepsis Assessment and Identification in Low Resource Settings (SAILORS) Collaboration 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 (Ն2) 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). RESULTSThe 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.

Downregulation of JKAP is correlated with elevated disease risk, advanced disease severity, higher inflammation, and poor survival in sepsis

“…SOFA score reflects the facets of organ dysfunction; therefore, the sepsis patients with high SOFA score might have more severe organ dysfunction, which contributed to the undesirable survival. 16,17 Additionally, IL-1β was a well-known proinflammatory cytokine; therefore, the high expression of IL-1β might lead to the activation of the inflammasome response, as well as predict the worse survival in sepsis patients. 18 There were several limitations to our studies.…”

The inability to walk unassisted at hospital admission as a valuable triage tool to predict hospital mortality in Rwandese patients with suspected infection

“…An interesting finding of our analysis was that the walking status at hospital admission was correlated with the qSOFA score count. The qSOFA score has been shown to be a significant risk factor for sepsis and death both in high- [7] as well as low-and middle-income countries [11]. Notably, the fifteen study patients of our cohort who could walk unassisted to hospital admission and had a qSOFA score �2 points all survived.…”

A learning health systems approach to improving the quality of care for patients in South Asia

“…NICST is a non-profit organisation which has developed a clinician-led, settingadapted continuous surveillance platform, supporting the delivery of acute medical, surgical and critical care for over 250,000 patients in South Asia [11,15,16]. The platform, part of a learning health system (LHS) methodology to improve acute care in LMICs, has enabled evaluation of patient outcomes, development of prognostic models, observational research and quality improvement through real-time information feedback and clinical training [11,[15][16][17]. The CQIN aims to develop an international network of health care workers, researchers, educators and administrators with capacity to improve acute care in LMIC settings.…”