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Prognostic Accuracy of Sepsis Criteria in the ED


January 18, 2017

By Will Boggs MD

NEW YORK (Reuters Health) - In patients with suspected infection presenting to the emergency department, the Sepsis-3 criteria accurately predict in-hospital mortality, according to the French Society of Emergency Medicine Collaborators Group.

"Sepsis-3 criteria should be adopted," Dr. Yonathan Freund from Hopital Pitie-Salpetriere in Paris told Reuters Health by email. "The new definitions and criteria that were expressed by the Sepsis-3 task force are validated with our study."

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) calls for use of the quick Sequential Organ Failure Assessment (qSOFA) score for risk stratification and consideration for sepsis in emergency department (ED) patients with infection. qSOFA scores range from 0-3, with 1 point each for respiratory rate >21 breaths/min, systolic blood pressure under 101 mmHg, or altered mental status.

qSOFA is a surrogate for the full SOFA score, which predicts ICU mortality based on lab results and clinical data. qSOFA had not been prospectively validated or studied specifically in the ED, according to the authors.

In 879 patients at 30 centers across Europe, Dr. Freund and colleagues tested qSOFa comparing their findings to results with prior guidelines that utilized the systemic inflammatory response syndrome (SIRS) score and serum lactate levels.

The qSOFA was 2 or higher for 25% of patients, SOFA was 2 or higher for 34% of patients, SIRS was 2 or higher for 74% of patients, and 20% of patients fulfilled previous criteria of severe sepsis (at least 2 elements of SIRS and a blood lactate concentration of >2 mmol/L), according to the January 17th JAMA report.

Overall in-hospital mortality was 8%. It was 24% for patients with a qSOFA of 2 or higher versus 3% for patients with lower qSOFA scores.

qSOFA was significantly better than the other measures for predicting in-hospital death, severe sepsis, ICU admission, ICU admission of more than 72 hours, and a composite of death or ICU admission of more than 72 hours.

qSOFA provided 70% sensitivity and 79% specificity for predicting in-hospital mortality, compared with 73% sensitivity and 70% specificity for SOFA.

After adjustment for age and site of infection, a qSOFA of 2 or higher was associated with a 6.2-fold increased risk of in-hospital mortality.

"qSOFA is much more adapted for the practice of emergency medicine," Dr. Freund said. "SIRS needed biological results; that results in a delay for the risk stratification. qSOFA can be obtained very easily, as soon as the patient is seen by a triage nurse or a physician."

Although the SOFA score was also accurate, "all of its component are rarely measured in routine practice in our EDs," he explained. "qSOFA is then more adapted to our practice."

Dr. Christopher W. Seymour from the University of Pittsburgh, Pennsylvania told Reuters Health by email, "Sepsis is a major health problem, and the early identification of cases is a high priority in the emergency department. The validation of qSOFA, a major component of Sepsis-3 criteria, in a prospective cohort is a major advance."

"Now that the model has been prospectively validated in multiple countries in the ED, greater adoption of the model may hinge on trials that use qSOFA as part of clinical decision algorithms," he said.

In a related study, researchers sought to assess the discriminatory capacities of an increase in SOFA score by 2 or more points, 2 or more SIRS criteria, or a qSOFA score of 2 or more points for outcomes among critically ill patients with suspected infection.

In their retrospective analysis of 184,875 ICU patients with an infection-related primary diagnosis, discrimination of in-hospital mortality was significantly greater using SOFA than using either SIRS criteria or qSOFA, according to Dr. Andrew A. Udy from Alfred Hospital, Melbourne, Victoria, Australia and colleagues from the Australian and New Zealand Intensive Care Society Center for Outcomes and Resource Evaluation.

SOFA also proved superior to both SIRS criteria and qSOFA for predicting the secondary outcome of hospital mortality or ICU stay of at least 3 days.

In-hospital mortality was 20.2% for patients who had an increase from baseline in SOFA score of 2 or more versus 4.4% for those without such increases.

"Amongst patients admitted to an intensive care unit with infection, use an increase in SOFA score of 2 or more to diagnose sepsis and identify those more likely to die," Dr. Udy concluded in his email. "This holds true for all patient groups, old or young, previously healthy or chronically ill. Don't rely on SIRS or qSOFA to diagnose sepsis within the ICU!"

"Ultimately, the utility of qSOFA will likely become surpassed if and when highly accurate, rapid diagnostic tests for sepsis emerge," write Dr. François Lamontagne and colleagues from Intensive Care National Audit and Research Center, London, UK in a related editorial. "For now, however, outside the ICU in the high-income settings where it has been tested, qSOFA appears a simple, rapid, inexpensive, and valid way to identify-among patients with suspected infection-those at a higher risk of having or developing sepsis."

SOURCE: http://bit.ly/2jkILJd, http://bit.ly/2jxiVUV and http://bit.ly/2k0jV09

JAMA 2017.

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