Predictive Accuracy of the Quick Sepsis-related Organ Failure Assessment Score in Brazil. A Prospective Multicenter Study

Abstract

Rationale: Although proposed as a clinical prompt to sepsis based on predictive validity for mortality, the Quick Sepsis-related Organ Failure Assessment (qSOFA) score is often used as a screening tool, which requires high sensitivity.Objectives: To assess the predictive accuracy of qSOFA for mortality in Brazil, focusing on sensitivity.Methods: We prospectively collected data from two cohorts of emergency department and ward patients. Cohort 1 included patients with suspected infection but without organ dysfunction or sepsis (22 hospitals: 3 public and 19 private). Cohort 2 included patients with sepsis (54 hospitals: 24 public and 28 private). The primary outcome was in-hospital mortality. The predictive accuracy of qSOFA was examined considering only the worst values before the suspicion of infection or sepsis.Measurements and Main Results: Cohort 1 contained 5,460 patients (mortality rate, 14.0%; 95% confidence interval [CI], 13.1-15.0), among whom 78.3% had a qSOFA score less than or equal to 1 (mortality rate, 8.3%; 95% CI, 7.5-9.1). The sensitivity of a qSOFA score greater than or equal to 2 for predicting mortality was 53.9% and the 95% CI was 50.3 to 57.5. The sensitivity was higher for a qSOFA greater than or equal to 1 (84.9%; 95% CI, 82.1-87.3), a qSOFA score greater than or equal to 1 or lactate greater than 2 mmol/L (91.3%; 95% CI, 89.0-93.2), and systemic inflammatory response syndrome plus organ dysfunction (68.7%; 95% CI, 65.2-71.9). Cohort 2 contained 4,711 patients, among whom 62.3% had a qSOFA score less than or equal to 1 (mortality rate, 17.3%; 95% CI, 15.9-18.7), whereas in public hospitals the mortality rate was 39.3% (95% CI, 35.5-43.3).Conclusions: A qSOFA score greater than or equal to 2 has low sensitivity for predicting death in patients with suspected infection in a developing country. Using a qSOFA score greater than or equal to 2 as a screening tool for sepsis may miss patients who ultimately die. Using a qSOFA score greater than or equal to 1 or adding lactate to a qSOFA score greater than or equal to 1 may improve sensitivity.Clinical trial registered with www.clinicaltrials.gov (NCT03158493).

Keywords: Quick Sepsis-related Organ Failure Assessment; Sepsis-related Organ Failure Assessment; organ dysfunction; sepsis; systemic inflammatory response syndrome.

Figure 1.

Study flow chart. In cohort 1, we included patients presenting outside of the ICU with infection but without organ dysfunction or sepsis. In cohort 2, we included only patients presenting outside the ICU with sepsis. ED = emergency department; ILAS = Instituto Latino-Americano de Sepsis; qSOFA = Quick Sepsis-related Organ Failure Assessment.

Figure 2.

In-hospital mortality rates according to the qSOFA score. (A) Cohort 1: patients presenting outside of the ICU with infection but without organ dysfunction or sepsis. The number of patients according to the type of hospital is not reported because there were only 241 patients from public hospitals. (B) Cohort 2: patients presenting outside the ICU with sepsis, both in all hospitals and categorized by public and private hospitals. qSOFA = Quick Sepsis-related Organ Failure Assessment.

Figure 3.

Discrimination of the different tools for prediction of in-hospital mortality for cohort 1 (patients presenting outside of the ICU with infection but without organ dysfunction or sepsis). P < 0.001 between qSOFA and the other tools (DeLong method) (21). qSOFA = Quick Sepsis-related Organ Failure Assessment; ROC = receiver operating characteristic; SIRS = systemic inflammatory response syndrome; SOFA = Sequential Organ Failure Assessment.