Positive qSOFA Research Articles

Surgical Management for Patients with Toxic Megacolon due to Ulcerative Colitis.

The present study reviewed cases of Toxic megacolon (TM) treated in our department, summarized the timing and technique of surgery, and considered key points for surgical management. This single-center retrospective study included the medical records of patients clinically diagnosed with TM who underwent surgery between 1985 and 2020. The diagnostic criteria and screening scores for sepsis, such as the systemic inflammatory response syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA) score, and Modified Early Warning Score (MEWS), were validated. The preoperative clinical features and perioperative findings were also investigated. There were eight male and six female patients. Nine patients (64.3%) satisfied the criteria for toxemia proposed by Narabayashi, and 10 patients (71.4%) fulfilled the SIRS criteria. A positive qSOFA score was confirmed in 1 patient (7.1%). The MEWS was high in 2 patients (14.3%). Intestinal perforation occurred in 2 patients (14.3%), and 1 of them died from disseminated intravascular coagulation. The mortality rate of TM with perforation was 50%. Eleven patients (78.6%) underwent total colectomy with end ileostomy. TM does not have well-defined diagnostic criteria, in addition to developing sometimes as borderline or fulminant cases, and must be recognized at an early stage, taking various findings into consideration. The criteria proposed by Narabayashi and the SIRS criteria, which met in a high percentage of our cases, are recommended as indicators for determining the toxicity of TM. It is also important to consider surgery in the early stages of TM, even if clinical findings do not meet all the criteria.

The utility of qSOFA in assessing outcomes of patients with acute heart failure in a level II hospital: a single-center retrospective analysis

Abstract Funding Acknowledgements None. Introduction High all-cause mortality is associated with acute heart failure (AHF) hospitalization, both when the condition first develops and when it worsens. Although there are several risk models for patients with chronic heart failure (CHF), it is unknown whether these scoring systems may be applied to patients with ADHF to predict their chance of developing the condition. Purpose Acute Heart failure (AHF) patients benefit from accurate risk assessment. Those stratified with worse prognosis may benefit more from continuous and close monitoring, with subsequent prompt intervention in case of deterioration. Currently, there is a lack of a universally accepted risk score that can accurately predict outcomes in acute heart failure (AHF). Undeniably, sepsis and AHF share several clinical features. These similarities encourage the sepsis-to-AHF translation of SOFA and qSOFA scores. We compared different scoring systems used in sepsis and assessed their predictive accuracy. Methodology This retrospective study included all patients with acute heart failure admitted in a private teaching hospital between January 2014 and January 2023. This study included newly admitted adult patients with new-onset AHF or acute on chronic heart failure. Baseline qSOFA, SIRS, and SOFA values were determined. Receiver Operating Characteristics - Area under the Curve (ROC-AUC) analysis assessed these scores' ability to predict mortality, whereas chi-square and Fischer's exact test assessed secondary outcome risk. Results 545 patients were included in the study. The majority were males with a mean age of 65 years. Most patients in the study required oxygen support, were classified as NOHRIA A, and with NYHA Functional Class II. Renal and respiratory failures were prominent upon arrival. About 11% met ≥2 points in qSOFA. Therein, systolic BP of <100 mmHg was the most frequent criterion met. The primary endpoint, that is in-hospital mortality, occurred in 9.52% of patients. A positive qSOFA, defined as a score of 2 or more, was consistent in the majority of those meeting the primary endpoint (Chi2 = 264.698, p<0.001). The ROC analysis of qSOFA (AUC 0.949, 95% CI 0.924–0.974, accuracy of 73%), SOFA (AUC 0.935, 95% CI 0.887–0.983, accuracy of 72%), and SIRS criteria (AUC 0.939, 95% CI 0.917–0.961, accuracy of 72%) show no fundamental differences regarding the prediction of the primary endpoint. Patients with positive qSOFA criteria were more frequently affected by organ failure (OR 5.386, p <0.001), needed more vasopressors (OR 4.921, p < 0.001), notably with an ejection fraction <40% (OR 3.363, p <0.001), and required mechanical ventilator support more often (OR 3.794, p<0.001). Conclusion In conclusion, qSOFA used in Acute Heart Failure is a valuable tool in the early detection of in-hospital mortality and detection of worse outcomes, hence should be considered when making therapeutic strategies and decisions.AUC for Primary OutcomesSecondary Outcomes

Predictors and Outcomes of Infections in ICU Patients With Cirrhosis: A Single-Center Observational Study.

Patients with cirrhosis are susceptible to infections, especially by multidrug-resistant organisms (MDROs). There are limited data on the incidence of culture-positive infections and the validity of Sepsis 3-criteria in patients with cirrhosis admitted to the intensive care unit (ICU) in India, which we aimed to assess. In this prospective study, we included consecutive patients with cirrhosis admitted to the ICU between November 1, 2021, and April 30, 2022. The primary objective was to compare the outcomes of patients with microbiologically proven infections with those without proven infections. The secondary objective was to assess the predictors of infections and mortality and the impact of drug-resistant organisms. A total of 298 patients (9.4% women) were included. The incidence of microbiologically proven infection was 34% (101/298; 95%CI=27.6-41.2). Most patients (61%) had healthcare-associated infections, Gram-negative organisms accounted for 75.3%, and bacteremia was the commonest site. Drug-resistant organisms accounted for 52.5% (53/101; 95%CI=39.3-68.7), of which 39.6% were multidrug-resistant (MDR) and 12.8% were extensively drug-resistant (XDR). Mortality was significantly higher in patients with proven infections than those without (61.4% vs. 44.2%; P=0.007). The sequential organ failure assessment (SOFA) score (OR=1.91; 95%CI=1.04-3.52; P<0.001) and presence of fever and/or positive quick SOFA (qSOFA; OR=1.91;1.04-3.52; P=0.03) were associated with an increased risk of infections. The SOFA score (OR=1.06;95%CI=1.002-1.12; P=0.04), MELD NA score (OR=1.08;95%CI=1.05-1.12; P<0.001), and presence of fever and/or positive qSOFA (OR=2.19; 95%CI=1.27-3.76; P=0.005) predicted mortality. One-third of the patients with cirrhosis admitted to the ICU had microbiologically proven infection, and the mortality rate in such patients was high. SOFA, qSOFA, and fever can predict microbiologically proven infections and mortality in patients with cirrhosis.

Validation of 'Quick Sequential Organ Failure Assessment Score' as a Screening Tool for Early Identification of Sepsis Patients in the Emergency Department.

Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year. The speed and appropriateness of therapy administered in the initial hours of treatment are likely to influence the outcome. We conducted a study to validate the clinical assessment score named'quick sequential organ failure assessment' (qSOFA) score for use in the early identification of sepsis patients in the emergency department. Our primary objective was to see the sensitivity and specificity of the qSOFA-score for diagnosing sepsis in the emergency department and our secondary objective was to compare the sensitivity of the qSOFA score with the National Early Warning (NEW) score in patients with sepsis. A prospective observational study was conducted at Max Super Speciality Hospital Saket, New Delhi, from July 2016 to January 2017. Adult patients presenting to the emergency department with clinical signs and symptoms suggestive of infection were enrolled as per the eligibility criteria and divided into two groupson the basis of their qSOFA score at presentation. Out of 120 patients who had a positive qSOFA score 30 were subsequently confirmed as having sepsis whereas in qSOFA negative group 14 patients were subsequently diagnosed as having sepsis. This leads to the fact that although the test has near-acceptable specificity, the sensitivity is quite low. Calculations of the secondary outcome, that is 28-day mortality, revealed that 17 patients out of 120 who had a positive qSOFA score died within 28 days of first presentation whereas in the control group, nine patients had died. This means it successfully predicted mortality in only 17 patients and failed to predict mortality in nine patients out of 26 patients that died. The p-value is 0.097 which indicates both poor sensitivity as well as specificity for predicting mortality. We also compared qSOFA with the NEW score and found the latter to have a better sensitivity for detecting sepsis. This study shows that the qSOFA score, which has been specifically designed for early detection of sepsis patients in the emergency department or a pre-hospital setting in whom infection is suspected on a clinical basis, does not seem to be a good screening tool for early detection of sepsis patients in the emergency department.

GENDER-RELATED VARIATIONS IN PATHOPHYSIOLOGICAL RESPONSES TO METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS PNEUMONIA AND SEPSIS.

In preclinical studies, the protective effects of female sex hormones and the immunosuppressive effects of male sex hormones were demonstrated. However, gender-related differences in multiorgan failure and mortality in clinical trials have not been consistently explained. This study aims to investigate gender-related differences in the development and progression of sepsis using a clinically relevant ovine model of sepsis. Adult Merino male (n=7) and female (n=7) sheep were surgically prepared with multiple catheters before the study. To induce sepsis, bronchoscopy instilled methicillin-resistant Staphylococcus aureus into sheep's lungs. The time from the bacterial inoculation until the modified Quick Sequential Organ Failure Assessment (q-SOFA) score became positive was measured and analyzed primarily. We also compared the SOFA score between these male and female sheep over time. Survival, hemodynamic changes, the severity of pulmonary dysfunction, and microvascular hyperpermeability were also compared. The time from the onset of bacterial inoculation to the positive q-SOFA in male sheep was significantly shorter than in female sheep. Mortality was not different between these sheep (14% vs. 14%). There were no significant differences in hemodynamic changes and pulmonary function between the two groups at any time point. Similar changes in hematocrit, urine output, and fluid balance were observed between females and males. The present data indicate that the onset of multiple organ failure and progression of sepsis is faster in male sheep than in female sheep, even though the severity of cardiopulmonary function is comparable over time. Further studies are warranted to validate the above results.

Performance of qSOFA Score as a Screening Tool for Sepsis in the Emergency Department.

Sepsis is the leading cause of mortality, and various scoring systems have been developed for its early identification and treatment. The objective was to test the ability of quick sequential organ failure assessment (qSOFA) score to identify sepsis and predict sepsis-related mortality in the emergency department (ED). We conducted a prospective study from July 2018 to April 2020. Consecutive patients with age ≥18 years who presented to the ED with a clinical suspicion of infection were included. Sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and odds ratio (OR) for sepsis related mortality on day 7 and 28 were measured. A total of 1200 patients were recruited; of which 48 patients were excluded and 17 patients were lost to follow-up. 54 (45.4%) of 119 patients with positive qSOFA (qSOFA >2) died at 7 days and 76 (63.9%) died at 28 days. A total of 103 (10.1%) of 1016 patients with negative qSOFA (qSOFA score <2) died at 7 days and 207 (20.4%) died at 28 days. Patients with positive qSOFA score were at higher odds of dying at 7 days (OR: 3.9, 95% confidence interval [CI]: 3.1-5.2, P < 0.001) and 28 days (OR: 6.9, 95% CI: 4.6-10.3, P < 0.001). The PPV and NPV with positive qSOFA score to predict 7- and 28-day mortality were 45.4%, 89.9% and 63.9%, 79.6%, respectively. The qSOFA score can be used as a risk stratification tool in a resource-limited setting to identify infected patients at an increased risk of death.

QSOFA does not predict bacteremia in patients with severe manifestations of sepsis.

Bloodstream infections in septic patients may be missed due to preceding antibiotic therapy prior to obtaining blood cultures. We leveraged the FABLED cohort study to determine if the quick Sequential Organ Failure Assessment (qSOFA) score could reliably identify patients at higher risk of bacteremia in patients who may have false negative blood cultures due to previously administered antibiotic therapy. We conducted a multi-centre diagnostic study among adult patients with severe manifestations of sepsis. Patients were enrolled in one of seven participating centres between November 2013 and September 2018. All patients from the FABLED cohort had two sets of blood cultures drawn prior to the administration of antimicrobial therapy, as well as additional blood cultures within 4 hours of treatment initiation. Participants were categorized according to qSOFA score, with a score ≥2 being considered positive. Among 325 patients with severe manifestations of sepsis, a positive qSOFA score (defined as a score ≥2) on admission was 58% sensitive (95% CI 48% to 67%) and 41% specific (95% CI 34% to 48%) for predicting bacteremia. Among patients with negative post-antimicrobial blood cultures, a positive qSOFA score was 57% sensitive (95% CI 42% to 70%) and 42% specific (95% CI 35% to 49%) to detect patients who were originally bacteremic prior to the initiation of therapy. Our results suggest that the qSOFA score cannot be used to identify patients at risk for occult bacteremia due to the administration of antibiotics pre-blood culture.

Diabetes mellitus is associated with increased risk of positive qSOFA score but not with increased ICU admission in patients undergoing ureteral stent placement for ureteral stone and suspected infection.

Patients presenting with an obstructing ureteral stone and urinary tract infection (UTI) are at risk for severe infectious complications. Historically, diabetes mellitus (DM) was considered a risk factor for the development of septic shock in these patients. This study aimed to evaluate DM's impact on risk of septic shock in ureteral stent placement for ureteral stone and presumed UTI. An institutional review board-approved, retrospective review was performed at two institutions. All patients who met the following criteria from July 2016 to April 2020 were included in the study: emergency department visit with obstructing ureteral stone, concern for UTI, and ureteral stent placement. The primary outcome of interest was the development of postoperative septic shock defined by sepsis with hypotension requiring vasopressor support for at least one hour. The study cohort was made up of 187 patients. Median age was 61 (range 16-91). Males represented 40.1% (n=75) of the population, while DM was present in 26.2% (n=49). Thirty-five of 143 patients (18.7%) met the criteria for postoperative septic shock. Quick Sequential Organ Failure Assessment (qSOFA) criteria were met by 11 (22.4%) patients with DM compared to 13 (9.5%) of patients without DM (p=0.026). This difference did not translate into significant differences in use of vasopressors, with DM cohorts requiring pressors in 11 (22.4%), and 241 (17.5%) in non-DM (p=0.523). Purulent urine was more frequently described in patients with DM (22 [44.9%] vs. 342 [4.8%], p=0.011). Intensive care unit (ICU) admissions were similar between DM and non-DM at 13(27.1%) vs. 29 (21.2%), respectively (p=0.543). ICU stay and length of stay were similar between cohorts. In this multicenter study of patients who underwent ureteral stenting for ureteral stone and presumed UTI, DM was not associated with an increased risk of development of septic shock but was associated with an increased risk of positive qSOFA score.

Abstract No.: ABS3159: Utility of prognostic scores in prediction of mortality after emergency surgery in COVID-19 patients – A prospective observational cohort study

Background and Aims:Pre-operative prognostic scoring in emergency surgeries is important for informed consent and optimum resource allocation. The accuracy of pre-operative prognostic scores in patients with coronavirus disease (COVID-19) has not been studied. This study aimed to evaluate prognostic scoring tools in COVID-19 patients.Methods:A prospective, observational cohort study was conducted in adults with confirmed COVID-19 infection within 7 weeks before or 1 week after emergency surgery. (1) Demographic data, prognostic risk scores [American Association of Anaesthesiologists Physical Classification (ASA), sequential organ failure assessment (SOFA), quick SOFA (qSOFA), Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM), and Portsmouth POSSUM (P-POSSUM) scores], and surgical and anaesthetic factors were noted along with morbidity and 30-day mortality. The correlation of prognostic scores and mortality was evaluated using univariate Cox proportional hazards regression, receiver operating characteristic curves (ROCs), Youden’s index, and the Hosmer–Lemeshow goodness-of-fit model.Results:Sixty-seven COVID-19 patients underwent emergency surgery during the study period. The overall mortality was 19%, with the highest in gastro-intestinal/general surgery and sinus surgery. Positive qSOFA and ASA 3E/4E were associated with 9.03 and 12.7 times higher mortality risk, respectively. Each unit increase of SOFA-, POSSUM-, and P-POSSUM-predicted mortality scores led to 50%, 7%, and 6% higher mortality. SOFA, POSSUM, and P-POSSUM area under the curve–ROC curves showed good discrimination between survivors and non-survivors (AUC 0.8829, 0.85, and 0.86, respectively).Conclusion:The overall mortality was comparable to the published literature. (2) SOFA, POSSUM, and P-POSSUM models are good prognostictools for predicting the post-operative 30-day mortality in COVID-19 patients. qSOFA, a simple, clinical, objective tool, also has an aprognostic value.

Performance of prognostic scores in prediction of 30-day postoperative mortality in COVID-19 patients after emergency surgery: A retrospective cohort study.

: Risk assessment with prognostic scoring, though important, is scarcely studied in emergency surgical patients with COVID-19 infection. We conducted a retrospective cohort study on adult emergency surgical patients with COVID-19 infection in our institute from 1 May 2020 to 31 October 2021 to find the 30-day postoperative mortality and predictive accuracy of prognostic scores. We assessed the demographic data, prognostic risk scores (American Society of Anesthesiologists-Physical Classification (ASA-PS), Sequential Organ Failure Assessment (SOFA), Quick SOFA (qSOFA), Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scores), surgical and anesthetic factors. We assessed the postoperative morbidity using the Clavien-Dindo scale and recorded the 30-day mortality. Correlation of prognostic scores and mortality was evaluated using Univariate Cox proportional hazards regression, receiver operating characteristic curve (ROC), Youden's index and Hosmer- Lemeshow goodness of fit model. Emergency surgery was performed in 67 COVID-19 patients with postoperative complication and 30-day mortality rate of 33% and 19%, respectively. A positive qSOFA and ASAPS IIIE/IVE had a 9.03- and 12.7-times higher risk of mortality compared to a negative qSOFA and ASA-PS IE/IIE (P &lt; 0.001), respectively. Every unit increase of SOFA, POSSUM and P-POSSUM scores was associated with a 50%, 18% and 17% higher risk of mortality, respectively. SOFA, POSSUM and P-POSSUM AUCROC curves showed good discrimination between survivors and non-survivors (AUC 0.8829, 0.85 and 0.86, respectively). SOFA score has a higher sensitivity to predict 30-day postoperative mortality as compared to POSSUM and P-POSSUM. However, in absence of a control group of non-COVID-19 patients, actual risk attributable to COVID-19 infection could not be determined.

Risk assessment and prognostic analysis of patients with splenic infarction in emergency department: a multicenter retrospective study

Splenic infarction is a thromboembolic disease that is frequently missed in acute settings. Previous reviews were rarely presented from a clinical perspective. We aimed to evaluate the clinical characteristics, risk factors with diagnostic value, and prognostic factors using large cohort data and a matched case–control study method. A retrospective medical record review of six hospitals in Taiwan from January 1, 2005, to August 31, 2020, was conducted. All patients who underwent contrast CT with confirmed the diagnosis of splenic infarction were included. Their characteristics were presented and compared to a matched control group with similar presenting characteristics. Prognostic factors were also analyzed. A total of 130 cases were included, two-thirds of whom presented with abdominal pain. Atrial fibrillation was the most common associated predisposing condition, followed by hematologic disease. A higher proportion of tachycardia, positive qSOFA score, history of hypertension or atrial fibrillation, leukocytosis, and thrombocytopenia were found in splenic infarction patients compared to their counterparts. An underlying etiology of infective endocarditis was associated with a higher proportion of ICU admission. Splenic infarction patients often presented with left upper abdominal pain and tachycardia. A history of hypertension, atrial fibrillation, a laboratory result of leukocytosis or thrombocytopenia may provide a clue for clinicians to include splenic infarction in the differential list. Among the patients diagnosed with splenic infarction, those with an underlying etiology of infectious endocarditis may be prone to deterioration or ICU admission.

Antibiotic Timing and Progression to Septic Shock Among Patients in the ED With Suspected Infection

Recent medical society opinions have questioned the use of early antimicrobials in patients with sepsis, but without septic shock. Is time from ED presentation to administration of antibiotics associated with progression to septic shock among patients with suspected infection? This was a retrospective cohort study from March 2007 through March 2020. All adults with suspected infection and first antimicrobial administered within 24h of triage were included. Patients with shock on presentation were excluded. We performed univariate and multivariate logistic regression analyses predicting progression to septic shock. Seventy-four thousand one hundred fourteen patient encounters were included in the study. Five thousand five hundred ten patients (7.4%) progressed to septic shock. Of the patients who progressed to septic shock, 88%had received antimicrobials within the first 5h from triage. In the multivariate logistic model, time (in hours) to first antimicrobial administration showed an OR of 1.03 (95%CI, 1.02-1.04; P< .001) for progression to septic shock and 1.02 (95%CI, 0.99-1.04; P= .121) for in-hospital mortality. When adjusted for severity of illness, each hour delayed until initial antimicrobial administration was associated with a 4.0%increase in progression to septic shock for every 1h up to 24h from triage. Patients with positive quick Sequential Organ Failure Assessment (qSOFA) results were given antibiotics at an earlier time point than patients with positive systemic inflammatory response syndrome (SIRS) score (0.82h vs1.2 h; P< .05). However, median time to septic shock was significantly shorter (P< .05) for patients with positive qSOFA results at triage (11.2 h) compared with patients with positive SIRS score at triage (26 h). Delays in first antimicrobial administration in patients with suspected infection are associated with rapid increases in likelihood of progression to septic shock. Additionally, qSOFA score has higher specificity than SIRS score for predicting septic shock, but is associated with a worse outcome, even when patients receive early antibiotics.

Recognition in Emergency Department of Septic Patients at Higher Risk of Death: Beware of Patients without Fever.

Background and Objectives: Chances of surviving sepsis increase markedly upon prompt diagnosis and treatment. As most sepsis cases initially show-up in the Emergency Department (ED), early recognition of a septic patient has a pivotal role in sepsis management, despite the lack of precise guidelines. The aim of this study was to identify the most accurate predictors of in-hospital mortality outcome in septic patients admitted to the ED. Materials and Methods: We compared 651 patients admitted to ED for sepsis (cases) with 363 controls (non-septic patients). A Bayesian mean multivariate logistic regression model was performed in order to identify the most accurate predictors of in-hospital mortality outcomes in septic patients. Results: Septic shock and positive qSOFA were identified as risk factors for in-hospital mortality among septic patients admitted to the ED. Hyperthermia was a protective factor for in-hospital mortality. Conclusions: Physicians should bear in mind that fever is not a criterium for defining sepsis; according to our results, absence of fever upon presentation might be indicative of greater severity and diagnosis of sepsis should not be delayed.

Clinical prediction rule is more useful than qSOFA and the Sepsis-3 definition of sepsis for screening bacteremia.

Clinical guidelines recommend blood cultures for patients suspected with sepsis and bacteremia. Sepsis-3 task force introduced the new definition of sepsis in 2016; however, the relationship between the Sepsis-3 definition of sepsis and bacteremia remains unclear. This study aimed to investigate how to detect patients who need blood cultures. Consecutive patients who visited the emergency department in our hospital with suspected symptoms of bacterial infection and with collected blood culture were retrospectively examined between April and September 2019. The relationship between bacteremia and Sepsis-3 definition of sepsis, and the relationship between bacteremia and clinical scores (quick-Sequential Organ Failure Assessment [qSOFA], systematic inflammatory response syndrome [SIRS], and Shapiro's clinical prediction rule) were investigated. In any scores used, ≥2 points were considered positive. Among the 986 patients who met the inclusion criteria, 171 (17%) were complicated with bacteremia and 270 (27%) were patients with sepsis. Sepsis was more frequent (61% vs. 20%, P<0.001) and all clinical scores were more frequently positive in patients with bacteremia than in those without (qSOFA, 23% vs. 9%; SIRS, 72% vs. 58%; Shapiro's clinical prediction rule, 88% vs. 49%; P<0.001). Specificity to predict bacteremia was high in sepsis and positive qSOFA (0.80 and 0.91, respectively), whereas sensitivity was high in positive SIRS and Shapiro's clinical prediction rule (0.72 and 0.88, respectively); however, no clinical definitions and scores had both high sensitivity and specificity. The area under the receiver operating characteristic curves were 0.59 (95% confidence interval, 0.55-0.64), 0.60 (0.56-0.65), and 0.78 (0.74-0.82) in qSOFA, SIRS, and Shapiro's clinical prediction rule, respectively. Blood cultures should be obtained for patients with sepsis and positive qSOFA because of its high specificities to predict bacteremia; however, because of low sensitivities, Shapiro's clinical prediction rule can be more efficiently used for screening bacteremia.

Variation of vital signs with potential to influence the performance of qSOFA scoring in the Ethiopian general population at different altitudes of residency: A multisite cross-sectional study.

IntroductionThe physiological range of different vital signs is dependent on various environmental and individual factors. There is a strong interdependent relationship between vital signs and health conditions. Deviations of the physiological range are commonly used for risk assessment in clinical scores, e.g. respiratory rate (RR) and systolic blood pressure (BPsys) in patients with infections within the quick sequential organ failure assessment (qSOFA) score. A limited number of studies have evaluated the performance of such scores in resource-limited health care settings, showing inconsistent results with mostly poor discriminative power. Divergent standard values of vital parameters in different populations, e.g. could influence the accuracy of various clinical scores.MethodsThis multisite cross-sectional observational study was performed among Ethiopians residing at various altitudes in the cities of Asella (2400m above sea level (a.s.l.)), Adama (1600m a.s.l.), and Semara (400m a.s.l.). Volunteers from the local general population were asked to complete a brief questionnaire and have vital signs measured. Individuals reporting acute or chronic illness were excluded.ResultsA positive qSOFA score (i.e. ≥2), indicating severe illness in patients with infection, was common among the studied population (n = 612). The proportion of participants with a positive qSOFA score was significantly higher in Asella (28.1%; 55/196), compared with Adama, (8.3%; 19/230; p<0.001) and Semara (15.1%; 28/186; p = 0.005). Concerning the parameters comprised in qSOFA, the thresholds for RR (≥22/min) were reached in 60.7%, 34.8%, and 38.2%, and for BPsys (≤100 mmHg) in 48.5%, 27.8%, and 36.0% in participants from Asella, Adama, and Semara, respectively.DiscussionThe high positivity rate of qSOFA score in the studied population without signs of acute infection may be explained by variations of the physiological range of different vital signs, possibly related to the altitude of residence. Adaptation of existing scores using local standard values could be helpful for reliable risk assessment.

Role of Sepsis-3 Criteria and C-Reactive Protein in the Diagnosis of Sepsis in Critically ill Patients

Introduction: In the recent days, large proportion of the Intensive Care Unit (ICU) admissions ending in poor outcomes is impacted by pathological conditions like sepsis and septic shock. Hence, early diagnosis and appropriate therapy within the first hours of hospital admission plays a major role. Simple markers like C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), blood counts are still relied upon for suspected sepsis cases. Aim: To study the prevalence of sepsis and to evaluate the utility of the simple ideal markers like CRP, ESR, and blood counts for early diagnosis of sepsis in critically ill patients. Materials and Methods: This was a prospective observational study performed in the ICU of KMCH Institute of Allied Health Sciences, Coimbatore, Tamil Nadu, India, using 112 blood samples collected from patients admitted with clinical suspicion of sepsis. The samples were subjected to CRP estimation using turbidimetric immunoassay and blood culture. The data obtained were analysed using Statistical Package for the Social Sciences (SPSS) software version 21.0. The sensitivity, specificity, negative and positive predictive values were calculated. Results: Among a total of 112, the number of patients who abided the sepsis-3 definitions with positive qSOFA (quick Sepsis related Organ Failure Assessment) score was 50%. The most common co- morbid condition among the sepsis patients were diabetes mellitus (39.2%). The most frequent site of infection was respiratory tract (37.5%). Majority of infections were by gram-negative organisms (82%), the commonly isolated gram negative organisms were Klebsiella pneumoniae (25.9%) and Escherichia coli (25.9%). The sensitivity of CRP was 81% and specificity was 49% while the Positive Predictive Value (PPV) and Negative Predictive Value (NPV) was 60% and 56%, respectively. The prevalence of sepsis in present study was 50%. Conclusion: The study highlights the usefulness of CRP in identifying patients with sepsis in those who present with positive qSOFA score. Also, CRP could be very useful in resource-limited places, where newer biomarkers and guidance of an intensivist or sepsis expert are not available.

Use of quick sequential organ failure assessment score-based sepsis clinical decision support system may be helpful to predict sepsis development

Objectives: A sepsis clinical decision support system (CDSS) can facilitate quicker sepsis detection and treatment and consequently improve outcomes. We developed a qSOFA-based sepsis CDSS and evaluated its impact on compliance with a 3-hour resuscitation bundle for patients with sepsis. Methods: This before-and-after study included consecutive adult patients with suspected infection and qSOFA scores of ≥ 2 at their emergency department (ED) presentation of a tertiary care hospital. Sepsis was defined according to the Sepsis-3 criteria. We evaluated the 3-hour resuscitation bundle compliance rate for control patients from July through August 2016, for patients using the qSOFA-based sepsis CDSS from September through December 2016, and the impact of the system using multivariable logistic regression analysis. Results: Of 306 patients with suspected infection and positive qSOFA scores at presentation, 265 patients (86.6%) developed sepsis (including 71 patients with septic shock). The 3-hour resuscitation bundle compliance rate did not differ significantly between the patients before and after the routine implementation of the qSOFA-based sepsis CDSS (63.7% vs. 52.6%; P = 0.071). Multivariate analysis showed that age (AOR [adjusted odds ratio], 1.033; P = 0.002) and body temperature (AOR, 1.677; P &lt; 0.001) were associated with bundle compliance. Conclusions: Among patients with a positive qSOFA score at presentation, sepsis developed in 86.6%, which means the qSOFA-based sepsis CDSS may be helpful; however, it was not associated with improved bundle compliance. Future quality improvement studies with multifactorial, hospital-wide approaches using sepsis CDSS tools are warranted.

Accuracy of the qSOFA Score and RED Sign in Predicting Critical Care Requirements in Patients with Suspected Infection in the Emergency Department: A Retrospective Observational Study.

Background and objectives: We aimed to compare the accuracy of positive quick sequential organ failure assessment (qSOFA) scores and the RED sign in predicting critical care requirements (CCRs) in patients with suspected infection who presented to the emergency department (ED). Materials and Methods: In this retrospective observational study, we examined adult patients with suspected infection in the ED from June 2018 to September 2018. A positive qSOFA (qSOFA+) was defined as the presence of ≥2 of the following criteria: altered mental status (AMS), systolic blood pressure (SBP) < 100 mmHg, and respiratory rate (RR) ≥ 22 breaths/min. A positive RED sign (RED sign+) was defined as the presence of at least one of the RED sign criteria: AMS, skin mottling, SBP < 90 mmHg, heart rate >130 beats/min, or RR > 30 breaths/min. A qSOFA/RED+ was defined as the presence of qSOFA+ or RED+. We applied these tools twice using the initial values upon ED arrival and all values within 2 h after ED arrival. The accuracy of qSOFA+, RED+, and qSOFA/RED+ in predicting CCR was assessed. Results: Data from 5353 patients with suspected infection were analyzed. The area under the receiver operating characteristic curve (AUC) of RED+ (0.67, 95% confidence interval [CI]: 0.65–0.70) and that of qSOFA/RED+ (0.68, 95% CI: 0.66–0.70, p < 0.01) were higher than the AUC of qSOFA+ (0.59, 95% CI: 0.57–0.60) in predicting CCR on ED arrival. The qSOFA/RED+ within 2 h showed the highest accuracy (AUC 0.72, 95% CI: 0.70–0.75, p < 0.001). Conclusions: The accuracy of the RED sign in predicting CCR in patients with suspected infection who presented at ED was better than that of qSOFA. The combined use of the RED sign and qSOFA (positive qSOFA or RED sign) showed the highest accuracy.

QSOFA score for prediction of sepsis outcome in emergency department.

Objective:The third international consensus definition for sepsis and septic shock (sepsis 3) task force recently introduced qSOFA (quick sequential organ failure assessment) as a score for detection of patients at risk of sepsis outside of intensive care units. We performed this study to evaluate the validity of qSOFA for early detection and risk stratification of septic patients in emergency department.Methods:We conducted this study in an emergency department of the largest university affiliated hospital in northwest of Iran from Sept 2015 to Sept 2016. One hundred and forty patients who were SIRS positive with a suspected infection without alternative diagnosis and a microbiological proven infection were enrolled in this study. qSOFA was calculated for each patient and correlated with sepsis grades and mortality.Results:From 140 patients 84 (60%) had positive qSOFA score and 56 (40%) patients had negative qSOFA score. Our results showed that near half of patients with positive qSOFA expired during their stay in hospital while this was about 5% for patients with negative qSOFA. ROC curve of study regarding prediction of outcome with qSOFA showed an area under curve of 0.59. (P value: 0.04). Time spent to sepsis detection was 16 minutes shorter with qSOFA score compared to SIRS criteria in this study.Conclusion:In patients with suspected sepsis, qSOFA has acceptable value for risk stratification of severity, multi organ failure and mortality. It seems that education of medical staff and frequent screening of patients for warning signs can help to increase the value of qSOFA in prediction of mortality in critically ill septic patients.

The Use of qSOFA Score in the Elderly in an Internal Medicine Department—a Retrospective Cohort

With the increased presence of the elderly in the emergency department, sepsis represents a major cause of death. The Sepsis Taskforce developed the quick SOFA (qSOFA) score which consists of only 3 items, is quick and easy to apply, and establishes a mortality risk for patients. A retrospective review of electronic records of elderly patients, admitted during a year, with an infectious disease was made. Outcomes were in-hospital mortality, admission to intensive care unit, need for invasive mechanical ventilation, non-invasive mechanical ventilation, antibiotic escalation, and length of stay. In the 310 patients, 24% had a positive qSOFA score at admission. It correlated with increased mortality (2.7 times), also increased ICU admission (3.5 times), greater need for invasive ventilation (risk ratio 4.4), non-invasive ventilation (3 times higher), and a longer length of stay (2.3 days). qSOFA was a good predictor of IMV and NIMV need, ICU admission, and death.