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

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.

Figure 1.. Distribution of Patients (A) and Observed Mortality (B) by Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Score and Systemic Inflammatory Response Syndrome (SIRS) Criteria Among Patients With Suspected Infection in the Combined Cohort

Maximum qSOFA scores and SIRS criteria were calculated based on all available information in the first 24 hours after presentation to study hospital. Error bars indicate 95% CIs. Only those patients with known outcome status were included in the analytic sample for panel B.

Figure 2.. Risk Ratios and Odds Ratios for Hospital Mortality

A, Risk ratio for hospital mortality (log-scale) comparing encounters with ≥2 vs <2 Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) points and ≥2 vs <2 systemic inflammatory response syndrome (SIRS) criteria among patients with suspected infection by individual cohort. B, Odds ratio for hospital mortality (log-scale) comparing encounters with ≥2 vs <2 qSOFA points and ≥2 vs <2 SIRS criteria among patients with suspected infection by quartile of baseline risk for hospital mortality in the combined cohort. Only those patients with known outcome status (n = 6218) were included in the analytic sample. Overlaps in the quartile limits are due to rounding. Baseline risk determined based on age, sex, HIV status, and transfer status. Error bars indicate 95% CIs. For crude data, see eTables 3 and 4 in the Supplement for panels A and B, respectively.

Figure 3.. Discrimination of Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Score or Systemic Inflammatory Response Syndrome (SIRS) Criteria Added to Baseline Risk Model for Hospital Mortality Among Patients With Suspected Infection in the Individual and Combined Cohorts

Baseline risk determined based on age, sex, HIV status, and transfer status. The area under the receiver operating characteristic curve data derive from the baseline model alone, baseline model plus qSOFA score (range, 0-3), and baseline model plus SIRS criteria (range, 0-4). Error bars indicate 95% CIs. Only those patients with known outcome status (n = 6218) were included in the analytic sample.

Figure 4.. Receiver Operating Characteristic Curves for Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Score or Systemic Inflammatory Response Syndrome (SIRS) Criteria Added to Baseline Risk Model for Hospital Mortality Among Patients With Suspected Infection in the Combined Cohort

Baseline risk determined based on age, sex, HIV status, and transfer status. The area under the receiver operating characteristic curve (AUROC) data derive from the baseline model alone, baseline model plus qSOFA score (range, 0-3), and baseline model plus SIRS criteria (range, 0-4). AUROCs: baseline risk model, 0.56 (95% CI, 0.53-0.58); baseline risk plus qSOFA, 0.70 (95% CI, 0.68-0.72); and baseline risk plus SIRS, 0.59 (95% CI, 0.57-0.62).