Prognostic value of quickSOFA as a predictor of 28-day mortality among febrile adult patients presenting to emergency departments in Dar es Salaam, Tanzania

Abstract

Background: Quick Sequential Organ Failure Assessment (qSOFA) is a three-item clinical instrument for bedside identification of sepsis patients at risk of poor outcome. qSOFA could be a valuable triage tool in emergency departments of low-income countries, yet its performance in resource-limited settings remains unknown. The prognostic accuracy of qSOFA for 28-day all-cause mortality in febrile adults treated at the EDs in a low-income country was evaluated.

Methods: Retrospective analysis of a prospective cohort study of consecutive patients (≥18 years) with fever (tympanic temperature ≥38°C and fever ≤7 days) who presented between July 2013 and May 2014 at four emergency departments in Dar es Salaam, Tanzania. Medical history, clinical examination, laboratory and microbiological data were collected to document the cause of fever. Variables for the previous and new sepsis criteria were collected at inclusion and qSOFA, SOFA and SIRS were measured at inclusion. Patients were followed up by phone at day 28. The performance (sensitivity, specificity and area under the receiver operating curve [AUROC]) of qSOFA (score ≥2), SOFA (increase of ≥2 points) and SIRS (≥2 criteria) as predictors of 28-day all-cause mortality was evaluated.

Results: Among the 519 patients (median age: 30 years) included in the analysis, 47% were female and 25% were HIV positive. Overall, 85% had a microbiologically and/or clinically documented infection and 15% a fever of unknown origin. The most common site and causes of infections were the respiratory tract (43%), dengue (26%), malaria (6%) and typhoid fever (5%). Twenty-eight-day all-cause mortality was 6%: 3% for patients with a qSOFA <2 and 24% for those with a score ≥2 (absolute difference, 21%; 95% CI 12%-31%). The prognostic accuracy of qSOFA (AUROC 0.80, 95% CI 0.73-0.87) for 28-day mortality was similar to SOFA (AUROC 0.79, 0.71-0.87; p = 0.1) and better than SIRS (AUROC 0.61, 0.52-0.71; p<0.001).

Conclusions: Among patients with fever at emergency departments in Tanzania, qSOFA had a prognostic accuracy for 28-day mortality comparable to SOFA and superior to SIRS. These results support the use of qSOFA as a triage tool to identify patients with sepsis and at risk of poor outcome in resource-limited countries.

Trial registration: Clinicaltrials.gov Identifier: NCT01947075.

Conflict of interest statement

Prof. Thierry Calandra served as a board member for Abbott and Sobi Advisory Board. He also consulted for Immunexpress, Biocartis and Abtik. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. Flowchart of eligible patients and exclusion criteria.

Fig 2. Receiver operating characteristic (ROC) curves for 28-day mortality.

SOFA indicates Sequential (Sepsis-related) Organ Failure Assessment; qSOFA, quick SOFA; SIRS, systemic inflammatory response syndrome. The area under the ROC curves (AUROC) for qSOFA is 0.80 (95% CI 0.73–0.87), SOFA 0.79 (95% CI 0.71–0.87) and SIRS 0.61 (95% CI 0.52–0.71).