Translating Sepsis-3 Criteria in Children: Prognostic Accuracy of Age-Adjusted Quick SOFA Score in Children Visiting the Emergency Department With Suspected Bacterial Infection

Abstract

Background: Recent attempts to translate Sepsis-3 criteria to children have been restricted to PICU patients and did not target children in emergency departments (ED). We assessed the prognostic accuracy of the age-adjusted quick Sequential Organ Failure Assessment score (qSOFA) and compared the performance to SIRS and the quick Pediatric Logistic Organ Dysfunction-2 score (qPELOD-2). We studied whether the addition of lactate (qSOFA-L) would increase prognostic accuracy.Methods: Non-academic, single-center, retrospective study in children visiting the ED and admitted with suspected bacterial infection between March 2013 and January 2018. We defined suspected bacterial infection as initiation of antibiotic therapy within 24 h after ED entry. Age-adjusted qSOFA, SIRS, qPELOD-2, and qSOFA-L scores were compared by area under the receiver operating characteristics curve (AUROC) analysis. Primary outcome measure was PICU transfer and/or mortality and secondary outcome was prolonged hospital length of stay.Results: We included 864 ED visits [474 (55%) male; median age 2.5 years; IQR 9 months-6 years], of which 18 were transferred to a PICU and 6 ended in death [composite outcome PICU transfer and/or mortality; 23 admissions (2.7%)]. 179 (22.2%) admissions resulted in prolonged hospital length of stay. PICU transfer and/or death was present in 22.5% of visits with qSOFA≥2 (n = 40) compared to 2.0% of visits with qSOFA<2 (n = 444) (p < 0.01). qSOFA tends to be the best predictor of PICU transfer and/or mortality (AUROC 0.72 (95% CI, 0.57–0.86) compared to SIRS [0.64 (95% CI, 0.53–0.74), p = 0.23] and qPELOD-2 [0.60 (95% CI, 0.45–0.76), p = 0.03)]. Prolonged hospital length of stay was poorly predicted by qSOFA (AUROC 0.53, 95% CI 0.46–0.59), SIRS (0.49, 95% CI 0.44–0.54), and qPELOD-2 (0.51, 95%CI 0.45–0.57). qSOFA-L resulted in an AUROC of 0.67 (95% CI, 0.50–0.84) for PICU transfer and/or mortality and an AUROC of 0.56 (95% CI, 0.46–0.67) for prolonged hospital length of stay.Conclusion: The currently proposed bedside risk-stratification tool of Sepsis-3 criteria, qSOFA, shows moderate prognostic accuracy for PICU transfer and/or mortality in children visiting the ED with suspected bacterial infection. The addition of lactate did not improve prognostic accuracy. Future prospective studies in larger ED populations are needed to further determine the utility of the qSOFA score.

Accuracy of a Modified qSOFA Score for Predicting Critical Care Admission in Febrile Children

“…Overall, the LqSOFA demonstrates superior discriminative ability than that reported with the qSOFA in the pediatric population, both in the current study and compared with previous research. 6,9,30 In the current study, the LqSOFA revealed the greatest positive predictive value of all 4 scoring systems, although this was only 34%. The low values for positive predictive value seen across all scoring systems likely reflect the low prevalence of sepsis within the ED population and highlight the difficulty in identifying such cases.…”

“…With a cutoff of $2, the score revealed excellent specificity but was limited by a relatively low sensitivity, consistent with sensitivities reported for the qSOFA in both adults and children. [7][8][9][10] Given that the these scores are designed as tools to aid clinician decision-making, rather than simply predict outcome, it has been argued that this rate of falsenegatives is unacceptably high. 10 However, a cutoff of $1 for the…”

“…A limitation of their study is the use of a PICU population, given that "quick" organ dysfunction scores are designed to alert the clinician to those at risk for sepsis, and most PICU patients will already have some sort of organ dysfunction and/or organ support. In an ED study, Van Nassau et al 9 assessed the ability of the qSOFA to predict PICU transfer and/or mortality, reporting an AUC of 0.72 and a sensitivity of 50%, although their study used a relatively small sample (n = 864). With our study, we provide further evidence that the qSOFA lacks the prognostic ability to justify its introduction into routine practice in the pediatric ED.…”

“…First, researchers in several studies in both adult and pediatric populations have reported poor sensitivity, ranging from 37% to 70% in predicting in-hospital mortality [6][7][8] and only 36% to 54% in predicting ICU admission. [7][8][9][10] Second, researchers in many qSOFA studies have used mortality as their primary outcome, 4,[6][7][8] but mortality in pediatric ED settings is ,1%, therefore critical care (CC) admission is a more suitable outcome because this allows assessment of whether the score can identify those patients requiring additional support, regardless of survival. 10 Third, hypotension is a late sign of pediatric septic shock.…”

“…Researchers of a small pediatric ED study comparing the qSOFA, quick Pediatric Logistic Organ Dysfunction-2, and SIRS criteria for their ability to predict mortality or ICU admission found the qSOFA had the greatest predictive validity but achieved only moderate prognostic accuracy. 9 To address these limitations, we amended the age-adjusted qSOFA to create a novel score known as the Liverpool quick Sequential Organ Failure Assessment (LqSOFA). Although different scoring systems vary in relation to the number of items considered, and the cutoffs applied, past literature indicates that respiratory, cardiovascular, and central nervous system alterations are the most consistent features of severe illness in children and adults.…”