Predictive Accuracy of the Quick Sepsis-related Organ Failure Assessment Score in Brazil. A Prospective Multicenter Study

Flavia R Machado, Alexandre B Cavalcanti, Mariana B Monteiro, Juliana L Sousa, Aline Bossa, Antonio T Bafi, Felipe Dal-Pizzol, Flavio G R Freitas, Thiago Lisboa, Glauco A Westphal, Andre M Japiassu, Luciano C P Azevedo, Instituto Latino-Americano de Sepsis network investigators, Rosane Maria Souza Costa Brandão, Yelnya Cardoso Silva Dória, Mônica Rocha de Melo Silva, Antonieta de Sousa Castro, Andre Luis Coutinho de Araujo Macedo, Ianna Lacerda Sampaio Braga, Nathane Carolina Vieira de Sales, Allan Christian Cardoso Cembranel, Carlos Álvaro Corrêa Araújo, Adriana da Costa Barros, Werciley Saraiva Vieira Junior, Mariane Conceição Paixão, Guilherme Marrêta Cavalcanti Ayres, Patricia Moreira de Araújo Lisboa, Pedro Ivandosvick Cordeiro de Oliveira, Narhayanne Kondratievans, Nafel Rosa Toledo, Priscilla Alexandrini de Oliveira, Elisangela Brunetti de Melo, Silvério Leonardo Macedo Garcia, Simone Martins Gonçalves, Laura Borja, Maria Amelia Ferreira Rocha, Mariana Avendanha Victoriano, Priscila Portes Almeida, Gilvânia Cristina Silva Oliveira, Marcelo Dias M de Assis Costa, Mário Sergio Prado, Aldo Peixoto de Melo, Cristina Coelho de Medeiros Pereira, Márcia Gregory Tavares Melo, Cláudia Miranda Starling, Marcelo Silva de Oliveira, Angela de Fátima Borges, Lidiane Miranda Milagres, Maria Augusta de Mendonça Lima, Clarice Paraiso Ribeiro, Fabiana Soares Araújo Dos Santos, Rejane Fernandes Queiroz Andrade, Maria Márcia Caetano Silva, Orlando Cesar Mantese, Roberta Reis Cunha, Edmilson Antônio Mariano, Fabrícia Moreira Amorim, Edgar De Brito Sobrinho, Milce Hellen Barros de Oliveira, Adrian Oliveira Lameira Veríssimo, Gustavo Spangenberg Tarre Borges, Ana Carolina Dino Durda, Kamila Lira Jatoba, Renata Alessandra Sadowski, César Helbel, Gilselena Kerbauy, Cintia Magalhaes Carvalho Grion, Caroline Tolentino Sanches, Camila Brito Borguezam, Cintia Magalhães Carvalho Grion, Fernanda Esteves Nascimento Barros, Beatriz da Silva Carvalho, Rosânia Maria de Araújo Oliveira, Marcus Otávio Torres Vieira, Isabelle Araujo Barros, Marilene Aparecida Batista da Silva, Bruno Franco Mazza, Francilene de Oliveira Mendes, Moyzes Pinto Coelho Duarte Damasceno, Mozart Bellas Rodrigues, Danilo Abreu Dos Santos F da Silva, Roberto José F Calheiros, Juana Souto Jardim, Antonio Felix Pereira, Monica Guedes Rodrigues, Luis Eduardo S Fontes, Lucia P Coelho, Luana M F Kling, Giselle Rouvenat Accioly, Edmundo Tommasi, Maurício Moura, Fábio Guilherme Santoro, Marcelo Foradini de Albuquerque, Luciana Wilken Roderjan, Elane Moreira de Mattos, Ranieri Carvalho Leitão, Marcelo London, Victor de Souza Cravo, Giovanna Camacho Asturi, Felipe Luiz de Castro Pereira, Giovana Colozza Mecatti, Thiago Corsi Filiponi, Felipe Pires Barbosa, Gilberto Friedman, Rafael Barberena Moraes, Jaqueline Sangiogo Haas, Glauco Adrieno Westphal, Álvaro Koenig, Renata Peralta Fujiwara, Alexandre Habitante, Debora Couto, Gisele da Silva Oliveira, Marlene Pereira de Aguia, Antonio Claudomiro Aparecido Beneventi, Carlos Augusto Jacob, Alexandra Silva, Mariana Yumi Okada, Nilza Sandra Lasta, Livia Maria Garcia Melro, Carolina Paparelli Lourenço, Ciro Parioto Neto, Antonielle Figueirêdo Macêdo, Lucas Fernandes, Bruno Adler Maccagnan Pinheiro Besen, Nislene Barbosa Viana, Karina Daniela Araujo Gomes Coqueti, Fabio de Carvalho Maurício, Isabela Miranda Lopes, Amadeu Fuzita Lopes, Barbara da Silva Del Orti, José Antônio Manetta, Rodnei de Freitas Baião, Cristiano Ramos de Morais, Otávio Monteiro Becker Jr, Diogo Boldim Ferreira, Paula Tuma, Nayara Rodrigues da Silva, Margarete Vilins, Eveline Silva Santos, Leticia Sandre Vendrame Saes, Viviane Kiuti, Fernanda Maciel Paschoin, Érika Simões Mesquita Valim Moreir, Graziela Moreira Xavier, Wagner Santa Catharina, Alcides Félix Terrível, Joaquim StoraniNeto, Marcos Antônio Cyrillo, Jose Eduardo Vasconcellos, Patrícia Aparecida Leandro, Luciano Severino da Silva, Marcela Portugal de Alencar Ribeiro, Andrea Magna Patriota de Oliveira, Eduardo de Souza Pacheco, Andreia Lima, Linus Pauling Fascina, Juliana Celli, Ricardo Ota Pereira, Pedro Ivo Monteiro Pacheco, Cristiane Maria Clares de Araujo Moreno, Fabiana Barros de Almeida, José Antonio Almeida da Rocha, Aline Siqueira Bossa, Alexandre de Matos Soeiro, Mucio Tavares de Oliveira Júnior, Jorge Fares, Horácio José Ramalho, Márcia Lopes, Silene Pereira Santana, Mariana Volpe Arnoni, Fernanda Betti Maffei, Juliana Vila Chã Bueno, Renato Augusto Tambelli, Luciana Pedral Sampaio Sgarbi, Roseli Calil, Carolina C Ribeiro-do-Valle, Vanessa Aparecida Vilas-Boas, Ana Paula Fernandes Fadoni, Brígida Aparecida Rosa Dos Reis, Mônica Ducchi, Luiz Fumio Matsumoto, Elisabete Ribeiro Insoliti, Rosianne de Vasconcelos, Vinícius Avellar Werneck, Sabrina Bernardez Pereira, Bruno Gonçalves de Campos Araujo, Josiane Francisca Ferreira, Rafael Di Domenico Mattos, Mirani Lucia Monteiro, Rodrigo Dos Santos Nascimento, Izac Alessandro Batista de Souza, André Luiz Honório Cardoso, Miguel Villa Nova Soeiro, Fernando Côrtes Remisio Figuinha, Mario Sérgio Moreno, Bruna Augusta Oliveira Pagliaro, Maria Beatriz Bonin Caraccio, Juliana Vidal Sartori de Carvalho, Luiz Eduardo Miranda Paciência, Humberto Bolognini Tridapalli, Lidia Fabiana da Silva Manske, Rafaela Mamus Correa Tridapalli, Flavia R Machado, Alexandre B Cavalcanti, Mariana B Monteiro, Juliana L Sousa, Aline Bossa, Antonio T Bafi, Felipe Dal-Pizzol, Flavio G R Freitas, Thiago Lisboa, Glauco A Westphal, Andre M Japiassu, Luciano C P Azevedo, Instituto Latino-Americano de Sepsis network investigators, Rosane Maria Souza Costa Brandão, Yelnya Cardoso Silva Dória, Mônica Rocha de Melo Silva, Antonieta de Sousa Castro, Andre Luis Coutinho de Araujo Macedo, Ianna Lacerda Sampaio Braga, Nathane Carolina Vieira de Sales, Allan Christian Cardoso Cembranel, Carlos Álvaro Corrêa Araújo, Adriana da Costa Barros, Werciley Saraiva Vieira Junior, Mariane Conceição Paixão, Guilherme Marrêta Cavalcanti Ayres, Patricia Moreira de Araújo Lisboa, Pedro Ivandosvick Cordeiro de Oliveira, Narhayanne Kondratievans, Nafel Rosa Toledo, Priscilla Alexandrini de Oliveira, Elisangela Brunetti de Melo, Silvério Leonardo Macedo Garcia, Simone Martins Gonçalves, Laura Borja, Maria Amelia Ferreira Rocha, Mariana Avendanha Victoriano, Priscila Portes Almeida, Gilvânia Cristina Silva Oliveira, Marcelo Dias M de Assis Costa, Mário Sergio Prado, Aldo Peixoto de Melo, Cristina Coelho de Medeiros Pereira, Márcia Gregory Tavares Melo, Cláudia Miranda Starling, Marcelo Silva de Oliveira, Angela de Fátima Borges, Lidiane Miranda Milagres, Maria Augusta de Mendonça Lima, Clarice Paraiso Ribeiro, Fabiana Soares Araújo Dos Santos, Rejane Fernandes Queiroz Andrade, Maria Márcia Caetano Silva, Orlando Cesar Mantese, Roberta Reis Cunha, Edmilson Antônio Mariano, Fabrícia Moreira Amorim, Edgar De Brito Sobrinho, Milce Hellen Barros de Oliveira, Adrian Oliveira Lameira Veríssimo, Gustavo Spangenberg Tarre Borges, Ana Carolina Dino Durda, Kamila Lira Jatoba, Renata Alessandra Sadowski, César Helbel, Gilselena Kerbauy, Cintia Magalhaes Carvalho Grion, Caroline Tolentino Sanches, Camila Brito Borguezam, Cintia Magalhães Carvalho Grion, Fernanda Esteves Nascimento Barros, Beatriz da Silva Carvalho, Rosânia Maria de Araújo Oliveira, Marcus Otávio Torres Vieira, Isabelle Araujo Barros, Marilene Aparecida Batista da Silva, Bruno Franco Mazza, Francilene de Oliveira Mendes, Moyzes Pinto Coelho Duarte Damasceno, Mozart Bellas Rodrigues, Danilo Abreu Dos Santos F da Silva, Roberto José F Calheiros, Juana Souto Jardim, Antonio Felix Pereira, Monica Guedes Rodrigues, Luis Eduardo S Fontes, Lucia P Coelho, Luana M F Kling, Giselle Rouvenat Accioly, Edmundo Tommasi, Maurício Moura, Fábio Guilherme Santoro, Marcelo Foradini de Albuquerque, Luciana Wilken Roderjan, Elane Moreira de Mattos, Ranieri Carvalho Leitão, Marcelo London, Victor de Souza Cravo, Giovanna Camacho Asturi, Felipe Luiz de Castro Pereira, Giovana Colozza Mecatti, Thiago Corsi Filiponi, Felipe Pires Barbosa, Gilberto Friedman, Rafael Barberena Moraes, Jaqueline Sangiogo Haas, Glauco Adrieno Westphal, Álvaro Koenig, Renata Peralta Fujiwara, Alexandre Habitante, Debora Couto, Gisele da Silva Oliveira, Marlene Pereira de Aguia, Antonio Claudomiro Aparecido Beneventi, Carlos Augusto Jacob, Alexandra Silva, Mariana Yumi Okada, Nilza Sandra Lasta, Livia Maria Garcia Melro, Carolina Paparelli Lourenço, Ciro Parioto Neto, Antonielle Figueirêdo Macêdo, Lucas Fernandes, Bruno Adler Maccagnan Pinheiro Besen, Nislene Barbosa Viana, Karina Daniela Araujo Gomes Coqueti, Fabio de Carvalho Maurício, Isabela Miranda Lopes, Amadeu Fuzita Lopes, Barbara da Silva Del Orti, José Antônio Manetta, Rodnei de Freitas Baião, Cristiano Ramos de Morais, Otávio Monteiro Becker Jr, Diogo Boldim Ferreira, Paula Tuma, Nayara Rodrigues da Silva, Margarete Vilins, Eveline Silva Santos, Leticia Sandre Vendrame Saes, Viviane Kiuti, Fernanda Maciel Paschoin, Érika Simões Mesquita Valim Moreir, Graziela Moreira Xavier, Wagner Santa Catharina, Alcides Félix Terrível, Joaquim StoraniNeto, Marcos Antônio Cyrillo, Jose Eduardo Vasconcellos, Patrícia Aparecida Leandro, Luciano Severino da Silva, Marcela Portugal de Alencar Ribeiro, Andrea Magna Patriota de Oliveira, Eduardo de Souza Pacheco, Andreia Lima, Linus Pauling Fascina, Juliana Celli, Ricardo Ota Pereira, Pedro Ivo Monteiro Pacheco, Cristiane Maria Clares de Araujo Moreno, Fabiana Barros de Almeida, José Antonio Almeida da Rocha, Aline Siqueira Bossa, Alexandre de Matos Soeiro, Mucio Tavares de Oliveira Júnior, Jorge Fares, Horácio José Ramalho, Márcia Lopes, Silene Pereira Santana, Mariana Volpe Arnoni, Fernanda Betti Maffei, Juliana Vila Chã Bueno, Renato Augusto Tambelli, Luciana Pedral Sampaio Sgarbi, Roseli Calil, Carolina C Ribeiro-do-Valle, Vanessa Aparecida Vilas-Boas, Ana Paula Fernandes Fadoni, Brígida Aparecida Rosa Dos Reis, Mônica Ducchi, Luiz Fumio Matsumoto, Elisabete Ribeiro Insoliti, Rosianne de Vasconcelos, Vinícius Avellar Werneck, Sabrina Bernardez Pereira, Bruno Gonçalves de Campos Araujo, Josiane Francisca Ferreira, Rafael Di Domenico Mattos, Mirani Lucia Monteiro, Rodrigo Dos Santos Nascimento, Izac Alessandro Batista de Souza, André Luiz Honório Cardoso, Miguel Villa Nova Soeiro, Fernando Côrtes Remisio Figuinha, Mario Sérgio Moreno, Bruna Augusta Oliveira Pagliaro, Maria Beatriz Bonin Caraccio, Juliana Vidal Sartori de Carvalho, Luiz Eduardo Miranda Paciência, Humberto Bolognini Tridapalli, Lidia Fabiana da Silva Manske, Rafaela Mamus Correa Tridapalli

Abstract

Rationale: Although proposed as a clinical prompt to sepsis based on predictive validity for mortality, the Quick Sepsis-related Organ Failure Assessment (qSOFA) score is often used as a screening tool, which requires high sensitivity.Objectives: To assess the predictive accuracy of qSOFA for mortality in Brazil, focusing on sensitivity.Methods: We prospectively collected data from two cohorts of emergency department and ward patients. Cohort 1 included patients with suspected infection but without organ dysfunction or sepsis (22 hospitals: 3 public and 19 private). Cohort 2 included patients with sepsis (54 hospitals: 24 public and 28 private). The primary outcome was in-hospital mortality. The predictive accuracy of qSOFA was examined considering only the worst values before the suspicion of infection or sepsis.Measurements and Main Results: Cohort 1 contained 5,460 patients (mortality rate, 14.0%; 95% confidence interval [CI], 13.1-15.0), among whom 78.3% had a qSOFA score less than or equal to 1 (mortality rate, 8.3%; 95% CI, 7.5-9.1). The sensitivity of a qSOFA score greater than or equal to 2 for predicting mortality was 53.9% and the 95% CI was 50.3 to 57.5. The sensitivity was higher for a qSOFA greater than or equal to 1 (84.9%; 95% CI, 82.1-87.3), a qSOFA score greater than or equal to 1 or lactate greater than 2 mmol/L (91.3%; 95% CI, 89.0-93.2), and systemic inflammatory response syndrome plus organ dysfunction (68.7%; 95% CI, 65.2-71.9). Cohort 2 contained 4,711 patients, among whom 62.3% had a qSOFA score less than or equal to 1 (mortality rate, 17.3%; 95% CI, 15.9-18.7), whereas in public hospitals the mortality rate was 39.3% (95% CI, 35.5-43.3).Conclusions: A qSOFA score greater than or equal to 2 has low sensitivity for predicting death in patients with suspected infection in a developing country. Using a qSOFA score greater than or equal to 2 as a screening tool for sepsis may miss patients who ultimately die. Using a qSOFA score greater than or equal to 1 or adding lactate to a qSOFA score greater than or equal to 1 may improve sensitivity.Clinical trial registered with www.clinicaltrials.gov (NCT03158493).

Keywords: Quick Sepsis-related Organ Failure Assessment; Sepsis-related Organ Failure Assessment; organ dysfunction; sepsis; systemic inflammatory response syndrome.

Figures

Figure 1.
Figure 1.
Study flow chart. In cohort 1, we included patients presenting outside of the ICU with infection but without organ dysfunction or sepsis. In cohort 2, we included only patients presenting outside the ICU with sepsis. ED = emergency department; ILAS = Instituto Latino-Americano de Sepsis; qSOFA = Quick Sepsis-related Organ Failure Assessment.
Figure 2.
Figure 2.
In-hospital mortality rates according to the qSOFA score. (A) Cohort 1: patients presenting outside of the ICU with infection but without organ dysfunction or sepsis. The number of patients according to the type of hospital is not reported because there were only 241 patients from public hospitals. (B) Cohort 2: patients presenting outside the ICU with sepsis, both in all hospitals and categorized by public and private hospitals. qSOFA = Quick Sepsis-related Organ Failure Assessment.
Figure 3.
Figure 3.
Discrimination of the different tools for prediction of in-hospital mortality for cohort 1 (patients presenting outside of the ICU with infection but without organ dysfunction or sepsis). P < 0.001 between qSOFA and the other tools (DeLong method) (21). qSOFA = Quick Sepsis-related Organ Failure Assessment; ROC = receiver operating characteristic; SIRS = systemic inflammatory response syndrome; SOFA = Sequential Organ Failure Assessment.

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