SOFA and qSOFA at admission to the emergency department: Diagnostic sensitivity and relation with prognosis in patients with suspected infection

The Clinical Utility of Albumin with Sequential Organ Failure Assessment (SOFA) in Improving 30-Day Mortality Prediction in Patients with Infection in the Emergency Department

BACKGROUND

The Sequential Organ Failure Assessment (SOFA) score is currently the primary prognostic tool used in patients with infections to predict sepsis and mortality, although its predictive role remains debated. Serum albumin values have been recently found to correlate with the severity of sepsis. The purpose of this study is to evaluate the clinical usefulness of albumin dosage on SOFA score prediction in infected patients.

METHODS

This prospective single-centre observational study was performed in 2021. We used the net reclassification improvement (NRI) technique to evaluate the additional prognostic value of serum albumin used together with the SOFA score in infected patients. The discriminatory abilities of the SOFA score alone, of albumin levels alone, and of the albumin levels together with (but not incorporated into) the SOFA score was evaluated by comparing the area under the curve of the corresponding receiver operating characteristic (ROC) curves.

RESULTS

We included 949 patients with an infectious status; 8.9% (84/949) died within 30 days of ED admission. The AUROC for the SOFA score was 0.802 (95% CI: 0.756-0.849) and the albumin level was 0.813 (95% CI: 0.775-0.852). The NRI found that serum albumin improved SOFA score predictions of 30-day mortality by 24.3% (p < 0.001), yielding an AUROC of 0.881 (95% CI: 0.848-0.912; p < 0.001).

CONCLUSIONS

Using serum albumin values together with the SOFA score can improve prognostic prediction in patients with infections evaluated in the ED.

Prediction of unfavorable outcomes in community-acquired bacteremia by SIRS, SOFA and qSOFA scores

BACKGROUND

Sepsis diagnostic and prognostic scoring systems have changed over time. It remains uncertain which scoring system is the best predictor of unfavorable outcomes. We aimed to evaluate prediction of community-acquired bacteremia (CAB) outcomes using on-admission systemic inflammatory response syndrome (SIRS), sequential organ failure assessment (SOFA) and quick sequential organ failure assessment (qSOFA).

METHODS

We present a retrospective observational cohort study of consecutive adult patients hospitalized with CAB over ten years. SIRS, qSOFA and SOFA scores calculated on admission were dichotomized as ≥2 or 0-1. Raw and adjusted incidence of a composite unfavorable outcome (death, septic shock, invasive mechanical ventilation, extra-corporeal membrane oxygenation, renal replacement therapy) over 35 days were compared.

RESULTS

Among 1930 patients, 1221 (63.3%) had SIRS, 196 (10.2%) had qSOFA, and 1117 (57.9%) had SOFA≥2. Respective raw and adjusted probabilities of the outcome were similar. Incidence for qSOFA≥2 was high (41.3%) and still considerable for qSOFA 0-1 (5.4%). SOFA≥2 indicated higher risk than SIRS≥2 (14.7% vs. 12.4%), while SOFA 0-1 indicated lower risk than SIRS 0-1 (1.2% vs. 3.1%). This relationship between SOFA and SIRS was also observed in patients with qSOFA 0-1.

CONCLUSIONS

qSOFA≥2 was associated with highest probability of unfavorable outcome, but dichotomized SOFA was more precise at high vs. low-risk distinction. Consecutive use of dichotomized qSOFA and SOFA on admission of adults with CAB enables fast and reliable identification of patients at high (qSOFA≥2, risk ~≥35%), moderate (qSOFA 0-1, SOFA≥2, risk ~10%), and low risk (qSOFA 0-1, SOFA 0-1, risk 1-2%) of subsequent unfavorable events.

SIRS, SOFA, qSOFA, and NEWS in the diagnosis of sepsis and prediction of adverse outcomes: a systematic review and meta-analysis

BACKGROUND

We compared Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), Quick Sepsis-related Organ Failure Assessment (qSOFA), and National Early Warning Score (NEWS) for sepsis diagnosis and adverse outcomes prediction.

METHODS

Clinical studies that used SIRS, SOFA, qSOFA, and NEWS for sepsis diagnosis and prognosis assessment were included. Data were extracted, and meta-analysis was performed for outcome measures, including sepsis diagnosis, in-hospital mortality, 7/10/14-day mortality, 28/30-day mortality, and ICU admission.

RESULTS

Fifty-seven included studies showed good overall quality. Regarding sepsis prediction, SIRS demonstrated high sensitivity (0.85) but low specificity (0.41), qSOFA showed low sensitivity (0.42) but high specificity (0.98), and NEWS exhibited high sensitivity (0.71) and specificity (0.85). For predicting in-hospital mortality, SOFA demonstrated the highest sensitivity (0.89) and specificity (0.69). In terms of predicting 7/10/14-day mortality, SIRS exhibited high sensitivity (0.87), while qSOFA had high specificity (0.75). For predicting 28/30-day mortality, SOFA showed high sensitivity (0.97) but low specificity (0.14), whereas qSOFA displayed low sensitivity (0.41) but high specificity (0.88).

CONCLUSIONS

NEWS independently demonstrates good diagnostic capability for sepsis, especially in high-income countries. SOFA emerges as the optimal choice for predicting in-hospital mortality and can be employed as a screening tool for 28/30-day mortality in low-income countries.

Systemic inflammatory response syndrome criteria (SIRS) and sepsis 3 criteria for assessing outcomes in sepsis: A prospective observational study

Background

Sepsis is a major cause of death in hospitalised patients worldwide. Most studies for assessing outcomes in sepsis are from the western literature. Sparse data from Indian settings are available comparing the systemic inflammatory response syndrome (SIRS), Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) (sepsis 3 criteria) for assessing outcomes in sepsis. In this study, we aimed to compare the SIRS criteria and sepsis 3 criteria to assess disease outcome at day 28 (recovery/mortality) in a North Indian tertiary care teaching hospital.

Methods

A prospective observational study was performed in the Department of Medicine from 2019 to early 2020. Patients admitted to the medical emergency with clinical suspicion of sepsis were included. Systemic inflammatory response syndrome, qSOFA and SOFA scores were calculated at the time of presentation to the hospital. Patients were followed through the course of their hospital stay.

Results

Out of 149 patients, 139 were included in the analysis. Patients who died had significantly higher mean SOFA, qSOFA scores and mean change in SOFA score than patients who survived (P value <0.01). There was no statistical difference between recovery and deaths at similar SIRS scores. A 40.30% fatality rate was recorded. Systemic inflammatory response syndrome had low Area Under Curve (AUC) (0.47) with low sensitivity (76.8) and specificity (21.7). SOFA had the maximum AUC (0.68) compared to qSOFA (0.63) and SIRS (0.47). SOFA also had the maximum sensitivity (98.1) while the qSOFA score had the maximum specificity (84.3).

Conclusion

SOFA and qSOFA scores had superior predictive ability as compared to the SIRS score in assessing mortality in sepsis patients.

Antibiotic Practice in Patients With Acute Abdomen Admitted to a Danish Regional Hospital: A Clinical Qualitative Assurance Study

Background Acute abdomen is often complicated by intra-abdominal infection requiring antibiotic therapy. Danish regional antibiotic guidelines emphasize the restricted use of broad-spectrum antibiotics such as cephalosporins. In this study, we aimed to evaluate antibiotic practices in relation to hospitalized patients with acute abdomen. Methodology This retrospective quality assurance study was conducted among patients admitted to the surgical emergency department at the North Denmark Regional Hospital during a four-month observation period. Data were extracted from electronic patient journals and entered in the Research Electronic Data Capture data management system for further analytical work. Results Of 331 patients, 174 (53%) were treated with antibiotics, of whom 98 (56%) had been treated with cephalosporin, 47 (27%) with benzylpenicillin and gentamicin, 22 (13%) with piperacillin/tazobactam, and seven (4%) with ciprofloxacin. Use of a cephalosporin-based antibiotic regimen was significantly more common in patients with acute appendicitis (75%) compared to other diagnostic groups, such as acute cholecystitis (57%), incarcerated hernia with strangulation (56%), acute pancreatitis (50%), and acute diverticulitis (30%). However, patients with uncomplicated diverticulitis (53%) were significantly more often treated with benzylpenicillin and gentamicin, whereas patients with complicated diverticulitis Hinchey stage 3-4 were significantly more often treated with piperacillin/tazobactam. In addition, as the severity of acute cholecystitis increased, it was more frequently treated with piperacillin/tazobactam. Conclusions The study revealed that cephalosporins are frequently used in patients hospitalized with acute abdomen. This finding conflicts with current regional antibiotic guidelines. Reinforcement of the guidelines is required as an essential measure against the development of antibiotic resistance associated with the use of cephalosporins.

Biomarkers of sepsis in pigs, horses and cattle: from acute phase proteins to procalcitonin

Sepsis is a complex clinical syndrome triggered by an inflammatory host response to an infection. It is usually complicated to detect and diagnose, and has severe consequences in human and veterinary health, especially when treatment is not started early. Therefore, efforts to detect sepsis accurately are needed. In addition, its proper diagnosis could reduce the misuse of antibiotics, which is essential fighting against antimicrobial resistance. This case is a particular issue in farm animals, as antibiotics have been traditionally given massively, but now they are becoming increasingly restricted. When sepsis is suspected in animals, the most frequently used biomarkers are acute phase proteins such as C-reactive protein, serum amyloid A and haptoglobin, but their concentrations can increase in other inflammatory conditions. In human patients, the most promising biomarkers to detect sepsis are currently procalcitonin and presepsin, and there is a wide range of other biomarkers under study. However, there is little information on the application of these biomarkers in veterinary species. This review aims to describe the general concepts of sepsis and the current knowledge about the biomarkers of sepsis in pigs, horses, and cattle and to discuss possible advances in the field.

The Ramathibodi early warning score as a sepsis screening tool does not reduce the timing of antibiotic administration

Background

Administration of antibiotics to septic patients within 1 h was recommended in 2018 by the Surviving Sepsis Campaign (SSC) as a strategy to improve survival outcomes. The use of sepsis screening tools in emergency departments (EDs) is important for early diagnosis and initiation of sepsis care. This study aimed to assess the impact of the Ramathibodi early warning score (REWs) on the administration of antibiotics within 1 h of presentation.

Methods

This was an observational retrospective cohort study with propensity score matching between the sepsis-3 criteria (pre-period) and the REWs (post-period) as screening tools in adult patients with sepsis in EDs. The primary outcome was the proportion of receiving antibiotics within 1 h of presentation in the pre- and post-periods.

Results

A total of 476 patients were analyzed without propensity matching. The proportion of antibiotic administration within 1 h was higher in patients screened using the REWs compared with standard of care in the total study population (79.5% vs. 61.4%, p < 0.001). After propensity score matching, 153 patients were included in both groups. The proportion of antibiotic administration within 1 h was similar in patients screened using the REWs and those receiving standard of care (79.7% vs. 80.4%, p = 0.886). However, time to intensive care unit (ICU) admission was faster in patients screened using the REWs. Delays in receiving antibiotics of longer than 3 h were associated with increased mortality (adjusted hazard ratio 7.04, 95% confidence interval 1.45 to 34.11, p = 0.015).

Conclusions

Implementing the REWs as a tool in sepsis screening protocols in EDs did not improve rates of antibiotic administration within 1 h as recommended by the SSC. However, time to ICU admission was improved after implementation of the REWs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-022-00420-w.

SOFA Score Plus Impedance Ratio Predicts Mortality in Critically Ill Patients Admitted to the Emergency Department: Retrospective Observational Study

Background: The Sequential Organ Failure Assessment (SOFA) is a scoring system used for the evaluation of disease severity and prognosis of critically ill patients. The impedance ratio (Imp-R) is a novel mortality predictor. Aims: This study aimed to evaluate the combination of the SOFA + Imp-R in the prediction of mortality in critically ill patients admitted to the Emergency Department (ED). Methods: A retrospective cohort study was performed in adult patients with acute illness admitted to the ED of a tertiary-care referral center. Baseline SOFA score and bioelectrical impedance analysis to obtain the Imp-R were performed within the first 24 h after admission to the ED. A Cox regression analysis was performed to evaluate the mortality risk of the initial SOFA score plus the Imp-R. Harrell’s C-statistic and decision curve analyses (DCA) were performed. Results: Out of 325 patients, 240 were included for analysis. Overall mortality was 31.3%. Only 21.3% of non-surviving patients died after hospital discharge, and 78.4% died during their hospital stay. Of the latter, 40.6% died in the ED. The SOFA and Imp-R values were higher in non-survivors and were significantly associated with mortality in all models. The combination of the SOFA + Imp-R significantly predicted 30-day mortality, in-hospital mortality, and ED mortality with an area under the curve (AUC) of 0.80 (95% CI: 74–0.86), 0.79 (95% CI: 0.74–0.86) and 0.75 (95% CI: 0.66–0.84), respectively. The DCA showed that combining the SOFA + Imp-R improved the prediction of mortality through the lower risk thresholds. Conclusions: The addition of the Imp-R to the baseline SOFA score on admission to the ED improves mortality prediction in severely acutely ill patients admitted to the ED.

Risk factors for unfavorable clinical outcomes in patients with brain abscess in South Korea

Background

Brain abscess can be life-threatening and manifest various neurological findings, although the mortality rate has decreased recently. We investigated the risk factors for unfavorable outcomes of patients with brain abscess.

Methods

A retrospective cohort study examined patients with brain abscess seen from May 2005 to December 2018 in a tertiary care hospital in Seoul, South Korea. We reviewed the medical records for clinical findings, therapeutic modalities, and prognostic factors of brain abscess. Unfavorable clinical outcomes were defined as death, moderate to severe disability with neurological deficits, or vegetative state at 1 year or at the time of discharge from outpatient follow-up.

Results

The study enrolled 135 patients: 65.2% were males; the mean age was 56 years. 35.6% had unfavorable outcomes. In multivariate analysis, higher Sequential Organ Failure Assessment (SOFA) (p < 0.001), pre-existing hemiplegia (p = 0.049), and higher Charlson comorbidity index (CCI) (p = 0.028) were independently associated with unfavorable outcomes.

Conclusions

Higher SOFA, pre-existing hemiplegia and higher Charlson comorbidity index were significant risk factors for unfavorable clinical outcomes in patients with brain abscess.

Prognostic Accuracy of VqSOFA for Predicting 28-day Mortality in Patients with Suspected Sepsis in the Emergency Department

BACKGROUND

Sepsis screening in the emergency department (ED) is challenging. The quick Sequential Organ Failure Assessment (qSOFA) score had poor accuracy for predicting mortality in both the intensive care unit and ED. High lactate levels were associated with an increased mortality. However, a previous study using lactate levels in combination with the qSOFA score did not observe a meaningful improvement in predictive accuracy. This study assessed the prognostic accuracy of venous lactate levels plus the qSOFA (VqSOFA) score for predicting 28-day mortality.

METHODS

Patients who visited the Ramathibodi ED with suspected sepsis were enrolled. The VqSOFA, qSOFA, and Sequential Organ Failure Assessment (SOFA) scores were calculated using the initial vital signs and laboratory values. Prognostic accuracy was measured using the area under the receiver operating characteristic (AUROC) curve of the VqSOFA score and Sepsis-3 criteria for predicting 28-day mortality.

RESULTS

In total, 1,139 patients were enrolled, 118 of whom died within 28 days of admission. The AUROCs of the VqSOFA, qSOFA, and SOFA scores were 0.851 (95% CI 0.813-0.889), 0.813 (95% CI 0.772-0.854), and 0.728 (95% CI 0.671-0.784), respectively. Using VqSOFA score ≥ 3 as the cutoff, the sensitivity, specificity, and positive likelihood ratio were 74.6%, 82.5%, and 4.25%, respectively. VqSOFA ≥ 3 was linked to a low probability of 28-day survival and higher odds of vasopressor and ventilator use within 24 h.

CONCLUSIONS

VqSOFA was more predictive of 28-day mortality and vasopressor and mechanical ventilator use than the qSOFA and SOFA scores.

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

Introduction

The 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 (BP_sys) 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.

Methods

This 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.

Results

A 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 BP_sys (≤100 mmHg) in 48.5%, 27.8%, and 36.0% in participants from Asella, Adama, and Semara, respectively.

Discussion

The 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.

Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study

Introduction

This study was proposed to compare the ability and accuracy of modified sequential organ failure assessment (mSOFA), quick SOFA (qSOFA), and qSOFA-65 in predicting the status of nontraumatic patients referred to hospital emergency departments (EDs).

Materials and methods

This study was a prospective design that performed on the 746 nontraumatic patients referred to the ED. Each patient data was collected using a demographic questionnaire, mSOFA, qSOFA, and qSOFA-65 scales. Related variables of each scale were recorded based on patients’ medical records. Then, the outcome of each patient in the ED was followed up and recorded. The severity and specificity of each scale were estimated by the area under receiver operating characteristic (AUROC) curve at 99% confidence interval (CI).

Results

The mean and standard deviation of scores were as follows: mSOFA = 4.40 ± 2.58, qSOFA = 0.50 ± 0.70, and qSOFA-65 = 0.92 ± 0.96. Patients requiring admission to the intensive care unit (ICU) were identified with AUROC curve as follows: mSOFA = 0.882 (99% CI = 0.778–0.865); qSOFA = 0.717 (99% CI = 0.662–0.773); and qSOFA-65 = 0.771 (99% CI = 0.721–0.820), which showed that mSOFA has higher sensitivity and specificity than the other two scales in identifying patients requiring admission to the ICU.

Conclusion

All three scales were found to be reliable for identifying nontraumatic patients at risk of death and patients requiring admission to the ICU. However, since the time and data required to complete qSOFA and qSOFA-65 are much less than those of mSOFA, it is recommended that qSOFA and especially qSOFA-65 be used in ED to identify critically ill nontraumatic patients.

How to cite this article

Ebrahimian A, Shahcheragh SMT, Fakhr-Movahedi A. Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study. Indian J Crit Care Med 2020;24(11):1045–1050.

Acute cytokine release syndrome after a first dose of pembrolizumab as second-line treatment for metastatic, programmed death-ligand 1-positive, non-small-cell lung cancer

INTRODUCTION

The use of programmed death-ligand 1 (PD-L1) checkpoint inhibitor therapy is expanding, although its adverse effects are not completely known. We report on a rare case of acute cytokine release syndrome related to pembrolizumab use in a patient with lung cancer.

CASE REPORT

A 79-year-old man with metastatic, PD-L1-positive, non-small-cell lung cancer developed a febrile condition associated with a systemic inflammatory response syndrome and suffered haemodynamic compromise four hours after the first intravenous administration of pembrolizumab. A thorough medical workup found no alternative cause and a grade 2 cytokine release syndrome (CRS) was diagnosed.Management and outcome: Aggressive fluid resuscitation and supportive therapy led to restitutio ad integrum.

DISCUSSION

Acute CRS after the administration of a PD-L1 inhibitor is infrequent but could be a fatal condition. Supportive treatment and, if necessary, corticosteroids should be considered.

Predictive performance of SOFA and qSOFA for in-hospital mortality in severe novel coronavirus disease

OBJECTIVES

The assessment of illness severity at admission can contribute to decreased mortality in patients with the coronavirus disease (COVID-19). This study was conducted to evaluate the effectiveness of the Sequential Organ Failure Assessment (SOFA) and Quick Sequential Organ Failure Assessment (qSOFA) scoring systems at admission for the prediction of mortality risk in COVID-19 patients.

METHODS

We included 140 critically ill COVID-19 patients. Data on demographics, clinical characteristics, and laboratory findings at admission were used to calculate SOFA and qSOFA against the in-hospital outcomes (survival or death) that were ascertained from the medical records. The predictive accuracy of both scoring systems was evaluated by the receiver operating characteristic (ROC) curve analysis.

RESULTS

The area under the ROC curve for SOFA in predicting mortality was 0.890 (95% CI: 0.826-0.955), which was higher than that of qSOFA (0.742, 95% CI 0.657-0.816). An optimal cutoff of ≥3 for SOFA had sensitivity, specificity, positive predictive value, and negative predictive value of 90.00%, 83.18%, 50.00%, and 97.80%, respectively.

CONCLUSIONS

This novel report indicates that SOFA could function as an effective adjunctive risk-stratification tool at admission for critical COVID-19 patients. The performance of qSOFA is accepted but inferior to that of SOFA.

Arterial blood gas as a prognostic indicator in patients with sepsis

Abnormal arterial blood gas (ABG) among patients with sepsis is an important prognostic indicator. All-cause mortality was the highest among patients with respiratory acidosis (4/9 = 44.4%), followed by those having metabolic acidosis (3/8 = 37.5%). Median length of hospital and intensive care unit stay was 15.75 days and 6.25 days for those with abnormal ABG and 11 and 3.5 days among those with normal ABG. Median health-care expenditure at the time of discharge or death of the patient was the highest in patients with respiratory acidosis ($14,473) and least in patients with normal ABG ($3,384) (average expenditure among patients with abnormal ABG was [$10,059]).