• Kristina E Rudd, Christopher W Seymour, Adam R Aluisio, Marc E Augustin, Danstan S Bagenda, Abi Beane, Jean Claude Byiringiro, ChangChung-Chou HCHDepartments of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania., L Nathalie Colas, DayNicholas P JNPJMahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford, United Kingdom., A Pubudu De Silva, Arjen M Dondorp, Martin W Dünser, M Abul Faiz, Donald S Grant, Rashan Haniffa, Nguyen Van Hao, Jason N Kennedy, Adam C Levine, Direk Limmathurotsakul, Sanjib Mohanty, François Nosten, Alfred Papali, Andrew J Patterson, John S Schieffelin, Jeffrey G Shaffer, Duong Bich Thuy, C Louise Thwaites, Olivier Urayeneza, Nicholas J White, T Eoin West, Derek C Angus, and Sepsis Assessment and Identification in Low Resource Settings (SAILORS) Collaboration.
• Department of Medicine and the International Respiratory and Severe Illness Center (INTERSECT), University of Washington, Seattle.
• JAMA. 2018 Jun 5; 319 (21): 220222112202-2211.

ImportanceThe quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score has not been well-evaluated in low- and middle-income countries (LMICs).ObjectiveTo assess the association of qSOFA with excess hospital death among patients with suspected infection in LMICs and to compare qSOFA with the systemic inflammatory response syndrome (SIRS) criteria.Design, Settings, And ParticipantsRetrospective secondary analysis of 8 cohort studies and 1 randomized clinical trial from 2003 to 2017. This study included 6569 hospitalized adults with suspected infection in emergency departments, inpatient wards, and intensive care units of 17 hospitals in 10 LMICs across sub-Saharan Africa, Asia, and the Americas.ExposuresLow (0), moderate (1), or high (≥2) qSOFA score (range, 0 [best] to 3 [worst]) or SIRS criteria (range, 0 [best] to 4 [worst]) within 24 hours of presentation to study hospital.Main Outcomes And MeasuresPredictive validity (measured as incremental hospital mortality beyond that predicted by baseline risk factors, as a marker of sepsis or analogous severe infectious course) of the qSOFA score (primary) and SIRS criteria (secondary).ResultsThe cohorts were diverse in enrollment criteria, demographics (median ages, 29-54 years; males range, 36%-76%), HIV prevalence (range, 2%-43%), cause of infection, and hospital mortality (range, 1%-39%). Among 6218 patients with nonmissing outcome status in the combined cohort, 643 (10%) died. Compared with a low or moderate score, a high qSOFA score was associated with increased risk of death overall (19% vs 6%; difference, 13% [95% CI, 11%-14%]; odds ratio, 3.6 [95% CI, 3.0-4.2]) and across cohorts (P < .05 for 8 of 9 cohorts). Compared with a low qSOFA score, a moderate qSOFA score was also associated with increased risk of death overall (8% vs 3%; difference, 5% [95% CI, 4%-6%]; odds ratio, 2.8 [95% CI, 2.0-3.9]), but not in every cohort (P < .05 in 2 of 7 cohorts). High, vs low or moderate, SIRS criteria were associated with a smaller increase in risk of death overall (13% vs 8%; difference, 5% [95% CI, 3%-6%]; odds ratio, 1.7 [95% CI, 1.4-2.0]) and across cohorts (P < .05 for 4 of 9 cohorts). qSOFA discrimination (area under the receiver operating characteristic curve [AUROC], 0.70 [95% CI, 0.68-0.72]) was superior to that of both the baseline model (AUROC, 0.56 [95% CI, 0.53-0.58; P < .001) and SIRS (AUROC, 0.59 [95% CI, 0.57-0.62]; P < .001).Conclusions And RelevanceWhen assessed among hospitalized adults with suspected infection in 9 LMIC cohorts, the qSOFA score identified infected patients at risk of death beyond that explained by baseline factors. However, the predictive validity varied among cohorts and settings, and further research is needed to better understand potential generalizability.

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