Prognostic evaluation of quick sequential organ failure assessment score in ICU patients with sepsis across different income settings

Abstract

Background: There is conflicting evidence on association between quick sequential organ failure assessment (qSOFA) and sepsis mortality in ICU patients. The primary aim of this study was to determine the association between qSOFA and 28-day mortality in ICU patients admitted for sepsis. Association of qSOFA with early (3-day), medium (28-day), late (90-day) mortality was assessed in low and lower middle income (LLMIC), upper middle income (UMIC) and high income (HIC) countries/regions.

Methods: This was a secondary analysis of the MOSAICS II study, an international prospective observational study on sepsis epidemiology in Asian ICUs. Associations between qSOFA at ICU admission and mortality were separately assessed in LLMIC, UMIC and HIC countries/regions. Modified Poisson regression was used to determine the adjusted relative risk (RR) of qSOFA score on mortality at 28 days with adjustments for confounders identified in the MOSAICS II study.

Results: Among the MOSAICS II study cohort of 4980 patients, 4826 patients from 343 ICUs and 22 countries were included in this secondary analysis. Higher qSOFA was associated with increasing 28-day mortality, but this was only observed in LLMIC (p < 0.001) and UMIC (p < 0.001) and not HIC (p = 0.220) countries/regions. Similarly, higher 90-day mortality was associated with increased qSOFA in LLMIC (p < 0.001) and UMIC (p < 0.001) only. In contrast, higher 3-day mortality with increasing qSOFA score was observed across all income countries/regions (p < 0.001). Multivariate analysis showed that qSOFA remained associated with 28-day mortality (adjusted RR 1.09 (1.00-1.18), p = 0.038) even after adjustments for covariates including APACHE II, SOFA, income country/region and administration of antibiotics within 3 h.

Conclusions: qSOFA was independently associated with 28-day mortality in ICU patients admitted for sepsis. In LLMIC and UMIC countries/regions, qSOFA was associated with early to late mortality but only early mortality in HIC countries/regions.

Keywords: APACHE; Critical care; Infection; Mortality; Prediction; qSOFA.

Fig. 1

Mortality associated with qSOFA score. Legend: All-cause mortality risk calculated from time of sepsis diagnosis to time of death. qSOFA, quick sequential organ failure assessment

Fig. 2

Mortality predictive performance of different scores across income regions/countries. Heatmap showing the area under the curve (AUC) of APACHE II, SOFA, SIRS, qSOFA and qSOFA with lactate to predict mortality across all income countries/regions. APACHE, Acute Physiology And Chronic Health Evaluation; qSOFA, quick sequential organ failure assessment; SIRS, systemic inflammatory response syndrome; SOFA, sequential organ failure assessment

Fig. 3

Proportion of clinical sepsis phenotype in different income countries/regions. Patients with sepsis were classified into four clinical sepsis phenotype groups according to fulflilment of score criteria: “SOFA only” (S), “SOFA and SIRS” (SS), “SOFA and qSOFA” (SqS) and “SOFA and SIRS and qSOFA” (SSqS). Distribution of patients with different clinical phenotypes across all income country/region groups. APACHE, Acute Physiology And Chronic Health Evaluation; qSOFA, quick sequential organ failure assessment; SIRS, systemic inflammatory response syndrome; SOFA, sequential organ failure assessment

Fig. 4

Clinical sepsis phenotype and associated all-cause mortality. Patients with sepsis were classified into four clinical sepsis phenotype groups according to fulflilment of score criteria: “SOFA only” (S), “SOFA and SIRS” (SS), “SOFA and qSOFA” (SqS) and “SOFA and SIRS and qSOFA” (SSqS). APACHE, Acute Physiology And Chronic Health Evaluation; qSOFA, quick sequential organ failure assessment; SIRS, systemic inflammatory response syndrome; SOFA, sequential organ failure assessment