S. Maitra, A. Som, S. Bhattacharjee

To identify sensitivity, specificity and predictive accuracy of quick sequential organ failure assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to predict in-hospital mortality in hospitalized patients with suspected infection.

José Moreira, Ariane Paixão, Juliana Oliveira, Waldir Jaló, Ofélio Manuel, Rafaela Rodrigues, Alexandra Oliveira, Leonardo Tinoco, João Lima, Beatriz Grinsztejn, Valdiléa G. Veloso, André M. Japiassú, Cristiane C. Lamas

To compare the discriminatory capacity of the quick Sequential Organ Failure Assessment (qSOFA) versus the Systemic Inflammatory Response Syndrome (SIRS) score for predicting 30-day mortality and intensive care unit (ICU) admission in patients with suspicion of infection at an HIV reference center.

Rudd KE, Seymour CW, Aluisio AR, et al.

This pooled cohort analysis assesses the association of quick Sequential (Sepsis-Related Organ Failure Assessment (qSOFA) score with excess hospital death among patients with suspected infection in low- to middle-income countries and compares the mortality association using qSOFA vs systemic inflammatory response syndrome (SIRS) criteria.

Abstract Background Community acquired bloodstream infection (CABSI) in low- and middle income countries is associated with a high mortality. This study describes the clinical manifestations, laboratory findings and correlation of SOFA and qSOFA with mortality in patients with CABSI in northern Vietnam. Methods This was a retrospective study of 393 patients with at least one positive blood culture with not more than one bacterium taken within 48 h of hospitalisation. Clinical characteristic and laboratory results from the first 24 h in hospital were collected. SOFA and qSOFA scores were calculated and their validity in this setting was evaluated. Results Among 393 patients with bacterial CABSI, approximately 80% (307/393) of patients had dysfunction of one or more organ on admission to the study hospital with the most common being that of coagulation (57.1% or 226/393). SOFA performed well in prediction of mortality in those patients initially admitted to the critical care unit (AUC 0.858, 95%CI 0.793–0.922) but poor in those admitted to medical wards (AUC 0.667, 95%CI 0.577–0.758). In contrast qSOFA had poor predictive validity in both settings (AUC 0.692, 95%CI 0.605–0.780 and AUC 0.527, 95%CI 0.424–0.630, respectively). The overall case fatality rate was 28%. HIV infection (HR = 3.145, p = 0.001), neutropenia (HR = 2.442, p = 0.002), SOFA score 1-point increment (HR = 1.19, p 

Abstract Purpose This retrospective cohort study derived a “quick” version of the Pitt bacteremia score (qPitt) using binary variables in patients with Gram-negative bloodstream infections (BSI). The qPitt discrimination was then compared to quick sepsis-related organ failure assessment (qSOFA) and systemic inflammatory response syndrome (SIRS). Methods Hospitalized adults with Gram-negative BSI at Palmetto Health hospitals in Columbia, SC, USA from 2010 to 2013 were identified. Multivariate Cox proportional hazards regression was used to determine variables associated with 14-day mortality. Results Among 832 patients with Gram-negative BSI, median age was 65 years and 449 (54%) were women. After adjustments for age and Charleston comorbidity score, all five components of qPitt were independently associated with mortality: temperature 

Cressman A, MacFadden D, Verma A, et al.

AbstractBackgroundPhysicians face competing demands of maximizing pathogen coverage, while minimizing unnecessary use of broad-spectrum antibiotics when managing sepsis. We sought to identify physicians’ perceived likelihood of coverage achieved by their usual empiric antibiotic regimen, along with minimum thresholds of coverage they would be willing to accept when managing these patients.MethodsWe conducted a scenario-based survey of internal medicine physicians from across Canada using a 2 x 2 factorial design, varied by infection source (undifferentiated vs. genitourinary) and severity (mild vs. severe) denoted by the Quick Sepsis Related Organ Failure Assessment (qSOFA) score. For each scenario, participants selected their preferred empiric antibiotic regimen, estimated the likelihood of coverage achieved by that regimen and considered their minimum threshold of coverage.ResultsWe had 238 respondents including 87 (36.6%) residents and 151 attending physicians (63.4%). The perceived likelihood of antibiotic coverage and minimum thresholds of coverage for each scenario were: 1) severe undifferentiated 90% [interquartile range (IQR) 89.5–95.0] and 90% [IQR 80–95], 2) mild undifferentiated 89% [IQR 80–95] and 80% [IQR 70–89.5], 3) severe GU 91% [IQR 87.3–95.0] and 90% [IQR 80.0–90.0], and 4) mild GU 90% [IQR 81.8–91.3%] and 80% [IQR 71.8–90]. Illness severity and infectious diseases specialty predicted higher thresholds of coverage whereas less clinical experience and lower self-reported prescribing intensity predicted lower thresholds of coverage.ConclusionPathogen coverage of 80% and 90% are physician-acceptable thresholds for managing patients with mild and severe sepsis from bacterial infections. These data may inform clinical guidelines and decision-support tools to improve empiric antibiotic prescribing.

Viale P, Tedeschi S, Scudeller L, et al.

AbstractBackground.To assess the impact on all-cause 14-day survival of the implementation of an infectious disease (ID) team for the early management of severe sepsis/septic shock (SS/SS) in the Emergency Department (ED).Methods.A quasi-experimental pre-post study was carried-out at the general ED of our 1,420-bed teaching hospital. During the pre phase (June 2013-July 2014) all consecutive adult patients with SS/SS were managed according to standard-of-care and data were prospectively collected. During the post phase (August 2014-October 2015), patients were managed in collaboration with a dedicated ID team by a bedside patient evaluation within 1 hour from ED arrival.Results.Overall, 382 patients were included, 195 in the pre and 187 in the post phase. Median age was 82 years (IQR 70-88). Most common infection sources were lung (43%) and urinary tract (17%), in 22% of cases infection source remained unknown. During the post phase the overall compliance with the Surviving Sepsis Campaign (SSC) bundle and the appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P<0.001), and from 30% to 79% (P<0.001), respectively. At multivariate analysis, predictors of 14-day mortality were: qSOFA >= 2 [HR 1.68, 1.15-2.45, P=0.007], serum lactate >= 2 mmol/L [HR 2.13, 1.39-3.25, P<0.001], and unknown infection source [HR 2.07, 1.42-3.02, P<0.001], while being attended during the post phase was a protective factor [HR 0.64, 0.43-0.94, P=0.026].Conclusion.The implementation of an ID team dedicated to the early management of SS/SS in ED improved the adherence to SSC recommendation and patient survival.

Shahin Gaini, Mette Marie Relster, Court Pedersen, Isik Somuncu Johansen

Adhikari NJ, Rubenfeld GD.

In the past 2 years, sepsis has received considerable attention from the global community. In 2017, the World Health Assembly passed a resolution urging all 194 UN Member States to implement actions to reduce the burden of sepsis, and for the World Health Organization to report on the public health implications of sepsis and its global consequences. It has become clear that early resuscitation targeted to hemodynamic goals is more expensive and no more effective than routine care in high-income countries. In Zambia, a protocolized resuscitation strategy actually increased mortality. These data and other studies continue to suggest that some evidence on sepsis therapy does not generalize on a global scale.

Christian Brun-Buisson

Meta-analyses of accuracy of the qSOFA to predict hospital mortality of patients with suspected infection show suboptimal performance of this abridged score. However, a score composed of only 3 clinical variables, such as the qSOFA or CRB can hardly be very accurate, but can serve as a warning integrated into clinical decision making, to help triaging patients in the ED. qSOFA does not help identifying infection. More complete, generic severity scores are nevertheless of major interest for stratification or analyses of epidemiolgical studies and clinical trials in septic patients.

Abstract Background The prognostic capability of the quick Sequential Organ Failure Assessment (qSOFA) bedside scoring tool is uncertain in non-ICU patients with sepsis due to bacteremia given the low number of patients previously evaluated. Methods We performed a retrospective cohort study of adult hospitalized patients with Staphylococcus aureus bacteremia (SAB). Medical charts were reviewed to determine qSOFA score, systemic inflammatory response syndrome (SIRS) criteria, and Pitt bacteremia score (PBS) at initial presentation; their predictive values were compared for ICU admission within 48 h, ICU stay duration > 72 h, and 30-day mortality. Results Four hundred twenty-two patients were included; 22% had qSOFA score ≥2. Overall, mean age was 56y and 75% were male. More patients with qSOFA ≥2 had altered mentation (23% vs 5%, p 

Lewis JM, Henrion M, Rylance J.

To the Editor Dr Rudd and colleagues concluded that the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score was superior to the systemic inflammatory response syndrome (SIRS) score and a baseline risk model in predicting in-hospital mortality in low- and middle-income countries (LMICs), an issue that has been debated since its introduction in the Sepsis-3 definitions. We are concerned that the treatment of missing data may have introduced significant bias.

Rudd KE, Seymour CW, Angus DC.

In Reply We agree with Dr Lewis and colleagues that missing data can be an important limitation in clinical research, including our analysis of the predictive validity of the qSOFA score and SIRS criteria. There are 2 issues related to missing data: (1) why missing data are present and (2) the approach to missing data during analysis. First, missing data were present in all 9 cohorts included in the study. Many sites lacked electronic health record systems, had limited medical staff available to collect and record serial vital signs, and were unable to routinely perform laboratory testing for every patient with suspected infection because of limited laboratory and financial resources. Given this reality, the diagnosis of sepsis in LMICs will not always be informed by complete data. Therefore, it is useful for clinicians in low-resource settings to understand the performance of alternative scoring systems in situations in which some variables, though important predictors of clinical outcome, may be missing.

F. Wu, Y. Ye, X. Zhou

We read with interest the meta-analysis by Maitra et al. who found that quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) seemed to be a poorly sensitive predictive marker for in-hospital mortality in hospitalized patients with suspected infection [1]. Though the review sounds comprehensive and scientific, we have some different views to address.