Abstract
To assess the value of the inability to walk unassisted to predict hospital mortality in patients with suspected infection in a resource-limited setting. This is a post hoc study of a prospective trial performed in rural Rwanda. Patients hospitalized because of a suspected acute infection and who were able to walk unassisted before this disease episode were included. At hospital presentation, the walking status was graded into: 1) can walk unassisted, 2) can walk assisted only, 3) cannot walk. Receiver operating characteristic (ROC) analyses and two-by-two tables were used to determine the sensitivity, specificity, negative and positive predictive values of the inability to walk unassisted to predict in-hospital death. One-thousand-sixty-nine patients were included. Two-hundred-one (18.8%), 315 (29.5%), and 553 (51.7%) subjects could walk unassisted, walk assisted or not walk, respectively. Their hospital mortality was 0%, 3.8% and 6.3%, respectively. The inability to walk unassisted had a low specificity (20%) but was 100% sensitive (CI95%, 90-100%) to predict in-hospital death (p = 0.00007). The value of the inability to walk unassisted to predict in-hospital mortality (AUC ROC, 0.636; CI95%, 0.564-0.707) was comparable to that of the qSOFA score (AUC ROC, 0.622; CI95% 0.524-0.728). Fifteen (7.5%), 34 (10.8%) and 167 (30.2%) patients who could walk unassisted, walk assisted or not walk presented with a qSOFA score count ≥2 points, respectively (p<0.001). The inability to walk unassisted correlated with the presence of risk factors for death and danger signs, vital parameters, laboratory values, length of hospital stay, and costs of care. Our results suggest that the inability to walk unassisted at hospital admission is a highly sensitive predictor of in-hospital mortality in Rwandese patients with a suspected acute infection. The walking status at hospital admission appears to be a crude indicator of disease severity.
Highlights
Infectious diseases and sepsis are leading causes of death in resource-limited nations [1,2]
The inability to walk unassisted had a low specificity (20%) but was 100% sensitive (CI95%, 90–100%) to predict inhospital death (p = 0.00007)
Our results suggest that the inability to walk unassisted at hospital admission is a highly sensitive predictor of in-hospital mortality in Rwandese patients with a suspected acute infection
Summary
Infectious diseases and sepsis are leading causes of death in resource-limited nations [1,2]. In a resource-limited environment differentiating between patients with significant infection who will develop life-threatening sepsis complications versus patients who will manifest serious infection only is difficult. Lack of routine diagnostic technology hampers the identification of patients with the highest risk of developing life-threatening sepsis [1,3]. It is our goal to translate improved identification of patients at hospital admission with the highest risk of death from infection into increased clinical support where appropriate. In order to reduce the death toll from infectious diseases in this setting, future research efforts should focus primarily on patients with an acute infection who are at risk of in-hospital death. While some modified illness scores have shown promise [5,6], no triage tool exists which could early and reliably differentiate between patients with a minimal risk of death and patients who are at risk of dying from their infectious process
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