Performance Characteristics of Sepsis Screening Tools During Delivery Admissions

Abstract

OBJECTIVE: To evaluate the screening performance characteristics of existing tools for the diagnosis of sepsis during delivery admissions. METHODS: This was a case–control study using electronic health record data, including vital signs and laboratory results, for all delivery admissions of patients with sepsis from 59 nationally distributed hospitals. Patients with sepsis were matched by gestational age at delivery in a 1:4 ratio with patients without sepsis to create a comparison group. Patients with chorioamnionitis and sepsis were compared with a complete cohort of patients with chorioamnionitis without sepsis. Multiple screening criteria for sepsis were evaluated: the CMQCC (California Maternal Quality Care Collaborative), SIRS (Systemic Inflammatory Response Syndrome), the MEWC (the Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System), and the MEWT (Maternal Early Warning Trigger Tool). Sensitivity, false-positive rates, and C-statistics were reported for each screening tool. Analyses were stratified into cohort 1, which excluded patients with chorioamnionitis–endometritis, and cohort 2, which included those patients. RESULTS: Delivery admissions at 59 hospitals were extracted for patients with sepsis. Cohort 1 comprised 647 patients with sepsis, including 228 with end-organ injury, matched with a control group of 2,588 patients without sepsis. Cohort 2 comprised 14,591 patients with chorioamnionitis–endometritis, of whom 1,049 had sepsis and 238 had end-organ injury. In cohort 1, the CMQCC and the UKOSS pregnancy-adjusted criteria had the lowest false-positive rates (6.9% and 9.6%, respectively) and the highest C-statistics (0.92 and 0.91, respectively). Although other screening criteria, such as SIRS and the MEWC, had similar sensitivities, it was at the cost of much higher false-positive rates (21.3% and 38.3%, respectively). In cohort 2, including all patients with chorioamnionitis–endometritis, the highest C-statistics were again for the CMQCC (0.67) and UKOSS (0.64). All screening tools had high false-positive rates, but the false-positive rates for the CMQCC and UKOSS were substantially lower than those for SIRS and the MEWC. CONCLUSION: During delivery admissions, the CMQCC and UKOSS pregnancy-adjusted screening criteria have the lowest false-positive results while maintaining greater than 90% sensitivity rates. Performance of all screening tools was degraded in the setting of chorioamnionitis–endometritis.

Performance Characteristics of Sepsis Screening Tools During Delivery Admissions

“…Given its significant contribution to maternal mortality, the detection and prevention of sepsis in pregnant and postpartum patients remains a key area of research. The retrospective case-control study by Main et al 1 These screening tools demonstrated a variable false-positive rate (6.9-11.6%), which increased when including patients with concomitant chorioamnionitis or endometritis. However, these statistical evaluations were calculated in a population with a fixed 20% prevalence of sepsis due to the 4:1 matching.…”

“…McDermott and Pier and Mr. Beltran for drawing attention to the challenges of screening for obstetric sepsis as outlined in our article in the March 2024 issue. 1 The concern for low specificity was addressed in the accompanying Editorial, 2 and we focused on it in our discussion. Obstetric sepsis is rare but appears to be more common than the authors note.…”

“…Given its significant contribution to maternal mortality, the detection and prevention of sepsis in pregnant and postpartum patients remains a key area of research. The retrospective case–control study by Main et al 1 in the March 2024 issue draws visibility to this clinical priority and provides a useful comparison of sepsis screening tools in a diverse population of obstetric patients. This study demonstrates superiority of the CMQCC (California Maternal Quality Care Collaborative) and UKOSS (United Kingdom Obstetric Surveillance System) sepsis screening criteria in detecting sepsis during intrapartum admissions.…”

Finding the Needle in the Haystack

“…In this month's issue of Obstetrics & Gynecology , Main et al 6 (see page 326) report the performance of pregnancy-adjusted sepsis screening tools in recognizing sepsis cases during delivery hospitalizations in 59 hospitals in the United States. The authors evaluated the screening criteria of five widely used sepsis screening systems.…”

In Reply:

“…McDermott and Pier and Mr. Beltran for drawing attention to the challenges of screening for obstetric sepsis as outlined in our article in the March 2024 issue. 1 The concern for low specificity was addressed in the accompanying Editorial, 2 and we focused on it in our discussion. Obstetric sepsis is rare but appears to be more common than the authors note.…”