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

Kristina E. Rudd, Christopher W. Seymour, Adam R. Aluisio, Marc E. Augustin, Danstan S. Bagenda, Abi Beane, Jean Claude Byiringiro, Chung Chou H. Chang, L. Nathalie Colas, Nicholas P.J. Day, A. Pubudu De Silva, Arjen M. Dondorp, Martin W. Dünser, M. Abul Faiz, Donald S. Grant, Rashan Haniffa, Nguyen Van Hao, Jason N. Kennedy, Adam C. Levine, Direk LimmathurotsakulSanjib Mohanty, François Nosten, Alfred Papali, Andrew J. Patterson, John S. Schieffelin, Jeffrey G. Shaffer, Duong Bich Thuy, C. Louise Thwaites, Olivier Urayeneza, Nicholas J. White, T. Eoin West, Derek C. Angus

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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.

Original languageEnglish (US)
Pages (from-to)2202-2211
Number of pages10
JournalJAMA - Journal of the American Medical Association
Volume319
Issue number21
DOIs
StatePublished - Jun 5 2018

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Systemic Inflammatory Response Syndrome
Hospital Mortality
Sepsis
Mortality
ROC Curve
Infection
Odds Ratio
Africa South of the Sahara
Intensive Care Units
Hospital Emergency Service
Inpatients
Cohort Studies
Randomized Controlled Trials
Demography
HIV
Research

ASJC Scopus subject areas

  • Medicine(all)

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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. / Rudd, Kristina E.; Seymour, Christopher W.; Aluisio, Adam R.; Augustin, Marc E.; Bagenda, Danstan S.; Beane, Abi; Byiringiro, Jean Claude; Chang, Chung Chou H.; Colas, L. Nathalie; Day, Nicholas P.J.; De Silva, A. Pubudu; Dondorp, Arjen M.; Dünser, Martin W.; Faiz, M. Abul; Grant, Donald S.; Haniffa, Rashan; Van Hao, Nguyen; Kennedy, Jason N.; Levine, Adam C.; Limmathurotsakul, Direk; Mohanty, Sanjib; Nosten, François; Papali, Alfred; Patterson, Andrew J.; Schieffelin, John S.; Shaffer, Jeffrey G.; Thuy, Duong Bich; Thwaites, C. Louise; Urayeneza, Olivier; White, Nicholas J.; West, T. Eoin; Angus, Derek C.

In: JAMA - Journal of the American Medical Association, Vol. 319, No. 21, 05.06.2018, p. 2202-2211.

Research output: Contribution to journalArticle

Rudd, KE, Seymour, CW, Aluisio, AR, Augustin, ME, Bagenda, DS, Beane, A, Byiringiro, JC, Chang, CCH, Colas, LN, Day, NPJ, De Silva, AP, Dondorp, AM, Dünser, MW, Faiz, MA, Grant, DS, Haniffa, R, Van Hao, N, Kennedy, JN, Levine, AC, Limmathurotsakul, D, Mohanty, S, Nosten, F, Papali, A, Patterson, AJ, Schieffelin, JS, Shaffer, JG, Thuy, DB, Thwaites, CL, Urayeneza, O, White, NJ, West, TE & Angus, DC 2018, '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', JAMA - Journal of the American Medical Association, vol. 319, no. 21, pp. 2202-2211. https://doi.org/10.1001/jama.2018.6229
Rudd, Kristina E. ; Seymour, Christopher W. ; Aluisio, Adam R. ; Augustin, Marc E. ; Bagenda, Danstan S. ; Beane, Abi ; Byiringiro, Jean Claude ; Chang, Chung Chou H. ; Colas, L. Nathalie ; Day, Nicholas P.J. ; De Silva, A. Pubudu ; Dondorp, Arjen M. ; Dünser, Martin W. ; Faiz, M. Abul ; Grant, Donald S. ; Haniffa, Rashan ; Van Hao, Nguyen ; Kennedy, Jason N. ; Levine, Adam C. ; Limmathurotsakul, Direk ; Mohanty, Sanjib ; Nosten, François ; Papali, Alfred ; Patterson, Andrew J. ; Schieffelin, John S. ; Shaffer, Jeffrey G. ; Thuy, Duong Bich ; Thwaites, C. Louise ; Urayeneza, Olivier ; White, Nicholas J. ; West, T. Eoin ; Angus, Derek C. / 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. In: JAMA - Journal of the American Medical Association. 2018 ; Vol. 319, No. 21. pp. 2202-2211.
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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.",
author = "Rudd, {Kristina E.} and Seymour, {Christopher W.} and Aluisio, {Adam R.} and Augustin, {Marc E.} and Bagenda, {Danstan S.} and Abi Beane and Byiringiro, {Jean Claude} and Chang, {Chung Chou H.} and Colas, {L. Nathalie} and Day, {Nicholas P.J.} and {De Silva}, {A. Pubudu} and Dondorp, {Arjen M.} and D{\"u}nser, {Martin W.} and Faiz, {M. Abul} and Grant, {Donald S.} and Rashan Haniffa and {Van Hao}, Nguyen and Kennedy, {Jason N.} and Levine, {Adam C.} and Direk Limmathurotsakul and Sanjib Mohanty and Fran{\cc}ois Nosten and Alfred Papali and Patterson, {Andrew J.} and Schieffelin, {John S.} and Shaffer, {Jeffrey G.} and Thuy, {Duong Bich} and Thwaites, {C. Louise} and Olivier Urayeneza and White, {Nicholas J.} and West, {T. Eoin} and Angus, {Derek C.}",
year = "2018",
month = "6",
day = "5",
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TY - JOUR

T1 - 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

AU - Rudd, Kristina E.

AU - Seymour, Christopher W.

AU - Aluisio, Adam R.

AU - Augustin, Marc E.

AU - Bagenda, Danstan S.

AU - Beane, Abi

AU - Byiringiro, Jean Claude

AU - Chang, Chung Chou H.

AU - Colas, L. Nathalie

AU - Day, Nicholas P.J.

AU - De Silva, A. Pubudu

AU - Dondorp, Arjen M.

AU - Dünser, Martin W.

AU - Faiz, M. Abul

AU - Grant, Donald S.

AU - Haniffa, Rashan

AU - Van Hao, Nguyen

AU - Kennedy, Jason N.

AU - Levine, Adam C.

AU - Limmathurotsakul, Direk

AU - Mohanty, Sanjib

AU - Nosten, François

AU - Papali, Alfred

AU - Patterson, Andrew J.

AU - Schieffelin, John S.

AU - Shaffer, Jeffrey G.

AU - Thuy, Duong Bich

AU - Thwaites, C. Louise

AU - Urayeneza, Olivier

AU - White, Nicholas J.

AU - West, T. Eoin

AU - Angus, Derek C.

PY - 2018/6/5

Y1 - 2018/6/5

N2 - 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.

AB - 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.

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