Mortality outcomes based on ED qSOFA score and HIV status in a developing low income country

Aluisio, Adam R.; Garbern, Stephanie Chow; Wiskel, Tess; Mutabazi, Zeta; Umuhire, Olivier; Ch'ng, Chin Chin; Rudd, Kristina E.; Nyinawankusi, Jeanne D’Arc; Byiringiro, Jean Claude; Levine, Adam C.

doi:10.1016/j.ajem.2018.03.014

Cited by 25 publications

(27 citation statements)

References 53 publications

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“…In the study presented here, qSOFA performance was in line with previous studies. [7][8][9]11 Regarding the UVA score, our study is, to the best of our knowledge, the first to perform a prospective validation of this score. In the original publication, Moore and others 14 describe an AUROC of 0.77 (95% CI: 0.75-0.79).…”

Section: Discussionmentioning

confidence: 97%

“…10 In Rwanda, qSOFA had a sensitivity of 36% (95% CI: 29-44%) and a specificity of 83% (95% CI: 79-86%) with an AUROC of 0.70 (95% CI: 0.65-0.75) for inhospital mortality. 9 In Tanzania, the sensitivity was 59% (95% CI: 41-76%) and specificity was 88% (95% CI: 84-91%) with an AUROC of 0.80 (95% CI: 0.73-0.87). 10 Finally, a multicenter retrospective secondary analysis on qSOFA was performed on nine studies in low-and middle-income countries from 2003 to 2017.…”

Section: Introductionmentioning

confidence: 95%

“…7 In addition, in a prospective observational study in patients with a suspected infection admitted to a tertiary hospital in Malawi, we observed a sensitivity of 72% (95% CI: 62-80%), a specificity of 68% (95% CI: 63-73%), and an AUROC of 0.73 (95% CI: 0.68-0.78). 8 Other groups retrospectively evaluated the qSOFA score in patients with an infection presenting to the emergency department of a tertiary care hospital in Rwanda 9 and in patients with suspected community-acquired infections presenting to the emergency department of a regional hospital in Tanzania. 10 In Rwanda, qSOFA had a sensitivity of 36% (95% CI: 29-44%) and a specificity of 83% (95% CI: 79-86%) with an AUROC of 0.70 (95% CI: 0.65-0.75) for inhospital mortality.…”

Section: Introductionmentioning

confidence: 99%

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A Prospective Comparison of Quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome Criteria, Universal Vital Assessment, and Modified Early Warning Score to Predict Mortality in Patients with Suspected Infection in Gabon

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Adégbitè

Gould

et al. 2019

The American Journal of Tropical Medicine and Hygiene

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The quick sequential organ failure assessment (qSOFA) score has been proposed for risk stratification of emergency room patients with suspected infection. Its use of simple bedside observations makes qSOFA an attractive option for resource-limited regions. We prospectively assessed the predictive ability of qSOFA compared with systemic inflammatory response syndrome (SIRS), universal vital assessment (UVA), and modified early warning score (MEWS) in a resource-limited setting in Lambaréné, Gabon. In addition, we evaluated different adaptations of qSOFA and UVA in this cohort and an external validation cohort from Malawi. We included 279 cases, including 183 with an ad hoc (suspected) infectious disease diagnosis. Overall mortality was 5%. In patients with an infection, oxygen saturation, mental status, human immunodeficiency virus (HIV) status, and all four risk stratification score results differed significantly between survivors and non-survivors. The UVA score performed best in predicting mortality in patients with suspected infection, with an area under the receiving operator curve (AUROC) of 0.90 (95% confidence interval [CI]: 0.78-1.0, P < 0.0001), outperforming qSOFA (AUROC 0.77; 95% CI: 0.63-0.91, P = 0.0003), MEWS (AUROC 0.72; 95% CI: 0.58-0.87, P = 0.01), and SIRS (AUROC 0.70; 95% CI: 0.52-0.88, P = 0.03). An amalgamated qSOFA score applying the UVA thresholds for blood pressure and respiratory rate improved predictive ability in Gabon (AUROC 0.82; 95% CI: 0.68-0.96) but performed poorly in a different cohort from Malawi (AUROC 0.58; 95% CI: 0.51-0.64). In conclusion, UVA had the best predictive ability, but multicenter studies are needed to validate the qSOFA and UVA scores in various settings and assess their impact on patient outcome.

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Section: Discussionmentioning

confidence: 97%

Section: Introductionmentioning

confidence: 95%

Section: Introductionmentioning

confidence: 99%

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A Prospective Comparison of Quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome Criteria, Universal Vital Assessment, and Modified Early Warning Score to Predict Mortality in Patients with Suspected Infection in Gabon

Schmedding

Adégbitè

Gould

et al. 2019

The American Journal of Tropical Medicine and Hygiene

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“…We conducted a secondary analysis of 9 data sets: 8 cohort studies (5 prospective and 3 retrospective) and 1 randomized clinical trial. [8][9][10][11][12][13][14][15] Of the countries represented in this study (Bangladesh, Haiti, India, Indonesia, Myanmar, Rwanda, Sierra Leone, Sri Lanka, Thailand, and Vietnam), 3 are classified as low income, 6 as lower middle income, and 1 as upper middle income by the World Bank. 16 Patients were recruited to the cohorts from a range of hospital settings, including small community hospitals, military hospitals, rural regional hospitals, national referral hospitals, and specialty infectious disease hospitals.…”

Section: Study Design Setting and Populationmentioning

confidence: 99%

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

Rudd

Seymour

Aluisio

et al. 2018

JAMA

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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.

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“…As such, research aimed at identifying,triaging and treating patients with sepsis early and appropriatelyis of high value. Such research could entail usingvital signs or simple clinical assessments such as the QuickSepsis-Related Organ Failure Assessment score and integrating these with accessible low-cost technology, suchas oxygen saturation monitoring, to determine setting appropriate risk stratification algorithms 40 41. Subsequently,these pathways could be linked to context-appropriate bundles of care which could be studied as an area of investigation pertinent to patient-centred outcomes.Studies to identify patients with infections who requireadmission versus those who can be managed as outpatientsmay also ease the burden in the lower-resourcedED.…”

Section: Key Research Focus Areasmentioning

confidence: 99%

Clinical emergency care research in low-income and middle-income countries: opportunities and challenges

et al. 2019

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Disease processes that frequently require emergency care constitute approximately 50% of the total disease burden in low-income and middle-income countries (LMICs). Many LMICs continue to deal with emergencies caused by communicable disease states such as pneumonia, diarrhoea, malaria and meningitis, while also experiencing a marked increase in non-communicable diseases, such as cardiovascular diseases, diabetes mellitus and trauma. For many of these states, emergency care interventions have been developed through research in high-income countries (HICs) and advances in care have been achieved. However, in LMICs, clinical research, especially interventional trials, in emergency care are rare. Furthermore, there exists minimal research on the emergency management of diseases, which are rarely encountered in HICs but impact the majority of LMIC populations. This paper explores challenges in conducting clinical research in patients with emergency conditions in LMICs, identifies examples of successful clinical research and highlights the system, individual and study design characteristics that made such research possible in LMICs. Derived from the available literature, a focused list of high impact research considerations are put forth.

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Mortality outcomes based on ED qSOFA score and HIV status in a developing low income country

Abstract: The qSOFA score provided risk stratification for both ED and hospital mortality outcomes in the setting studied, indicating utility in sepsis care in SSA, however, further prospective study in high-burden HIV populations is needed.

Cited by 25 publications

References 53 publications

A Prospective Comparison of Quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome Criteria, Universal Vital Assessment, and Modified Early Warning Score to Predict Mortality in Patients with Suspected Infection in Gabon

A Prospective Comparison of Quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome Criteria, Universal Vital Assessment, and Modified Early Warning Score to Predict Mortality in Patients with Suspected Infection in Gabon

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

Clinical emergency care research in low-income and middle-income countries: opportunities and challenges

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