Head-to-head comparison of qSOFA and SIRS criteria in predicting the mortality of infected patients in the emergency department: a meta-analysis

Abstract

Background: Recently, the concept of sepsis was redefined by an international task force. This international task force of experts recommended using the quick Sequential Organ Failure Assessment (qSOFA) criteria instead of the systemic inflammatory response syndrome (SIRS) criteria to classify patients at high risk for death. However, the added value of these new criteria in the emergency department (ED) remains unclear. Thus, we performed this meta-analysis to determine the diagnostic accuracy of the qSOFA criteria in predicting mortality in ED patients with infections and compared the performance with that of the SIRS criteria.

Methods: PubMed, EMBASE and Google Scholar (up to April 2018) were searched for related articles. A 2 × 2 contingency table was constructed according to mortality and qSOFA score (< 2 and ≥ 2) or SIRS score (< 2 and ≥ 2) in ED patients with infections. Two investigators independently assessed study eligibility and extracted data. We used a bivariate meta-analysis model to determine the prognostic value of qSOFA and SIRS in predicting mortality. We used the I² index to test heterogeneity. The bivariate random-effects regression model was used to pool the individual sensitivity, specificity, diagnostic odds ratio (DOR), positive likelihood ratio (PLR), and negative likelihood ratio (NLR). The summary receiver operating characteristic curve (SROC) was constructed to assess the overall diagnostic accuracy.

Results: Eight studies with a total of 52,849 patients were included. A qSOFA score ≥ 2 was associated with a higher risk of mortality in ED patients with infections, with a pooled risk ratio (RR) of 4.55 (95% CI, 3.38-6.14) using a random-effects model (I² = 91.1%). A SIRS score ≥ 2 was a prognostic marker of mortality in ED patients with infections, with a pooled RR of 2.75 (95% CI, 1.96-3.86) using a random-effects model (I² = 89%). When comparing the performance of qSOFA and SIRS in predicting mortality, a qSOFA score ≥ 2 was more specific; however a SIRS score ≥ 2 was more sensitive. The initial qSOFA values were of limited prognostic value in ED patients with infections.

Conclusions: A qSOFA score ≥ 2 and SIRS score ≥ 2 are strongly associated with mortality in ED patients with infections. However, it is also clear that qSOFA and SIRS have limitations as risk stratification tools for ED patients with infections.

Keywords: Emergency department; Infection; Mortality; Prognosis; SIRS; qSOFA.

Fig. 1

Flow diagram of the study selection process

Fig. 2

Deek’s funnel plot of publication bias (a). For qSOFA; b. For SIRS). Potential publication bias exists (P < 0.05)

Fig. 3

Forest plot of qSOFA scores ≥2 for predicting mortality in ED patients with infections

Fig. 4

Forest plot of the sensitivity and specificity of qSOFA scores ≥2 for predicting mortality in ED patients with infections

Fig. 5

Forest plot of SIRS scores ≥2 for predicting mortality in ED patients with infections

Fig. 6

Forest plot of the sensitivity and specificity of SIRS scores ≥2 on predicting mortality in ED patients with infections

Fig. 7

Paired specificity and sensitivity of qSOFA scores ≥2 versus SIRS scores ≥2 in predicting mortality in ED patients with infections