What’s New in Emergencies, Trauma and Shock - Quick Sequential Organ Failure Assessment Score and Sepsis in Resource-Limited Settings

The Global Burden of Disease study estimated that there were 48.9 million sepsis cases worldwide in 2017 and 11.0 million sepsis-related deaths. The highest burden has been estimated to be in low- and middle-income countries (LMICs).^[1] Infection and sepsis represent the two ends of a pathobiological continuum. Both have distinguishing definitions. Sepsis has an element of infection, host response, and organ dysfunction. Sepsis has been defined as life-threatening organ dysfunction due to a dysregulated host response to infection.^[1] The infection has to be suspected rather than proven and can be due to bacterial, fungal, viral, and parasitic pathogens. Early recognition and timely appropriate treatment are the cornerstone of a better clinical outcome in sepsis particularly in resource-limited settings. Sequential (or sepsis related) organ failure assessment (SOFA) score, has been recommended as the clinical criteria to measure the acute organ dysfunction in the Third International Consensus Definitions for Sepsis and Septic shock (Sepsis-3).^[1] SOFA score is the sine qua non for describing acute organ dysfunction in the absence of a standard reference for the accurate diagnosis of sepsis. However, the utility of SOFA is limited because variables like arterial blood gases are not measured routinely. Majority of the sepsis patients in resource-limited settings are managed in non-intensive care unit (ICU) settings. Tropical, subtropical, and LMICs share a unique burden of infections such as dengue, malaria, rickettsial diseases, leptospirosis, HIV infection, and enteric fever in addition to common Gram-negative and Gram-positive bacterial infections. The performance of screening and diagnostic tools for predicting mortality and organ dysfunction in adult patients with suspected infection or sepsis across different geographic regions has been variable.^[2] Multiple sepsis screening instruments have been developed and are being used for the identification of sepsis. Since the Sepsis-3 recommendation, most of the epidemiologic studies validating sepsis scores are from high-income countries and in addition to SOFA, have used quick SOFA (qSOFA) Score, systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score, Modified Early Warning Score and Logistic Organ Dysfunction System. In Sepsis-3, qSOFA score was proposed as a screening tool, to identify among adult patients with suspected infection at high risk of poor outcome.^[1] The advantages of qSOFA are that it requires only a clinical examination to describe the three clinical criteria. It is simpler to use, easy to obtain, easily repeated, available at the bedside, and can be applied by general practitioners. The sepsis-3 task force proposal if adapted then qSOFA can be used a triage tool to further investigate organ dysfunction, to initiate or escalate appropriate therapy and consider patients for advanced care setting monitoring. In addition, a positive qSOFA should alert the clinician of a possible infection in patients not previously recognized as infected.^[1] Data are available from LMICs and high-income countries to validate the instrument of qSOFA as a part of clinical decision-making tool among hospitalized patients with suspected infection. However, the discriminatory capacity of qSOFA in comparison to SOFA in defining sepsis has been evaluated and found to be of lesser capacity in the ICU settings.^[1,3] Among patients admitted to the ICU with suspected infection, defining sepsis by an increase in SOFA score provided greater prognostic accuracy for in-hospital mortality than either SIRS criteria or qSOFA.^[3] The qSOFA score may help identify patients at higher risk for excess hospital mortality among adults with suspected infection in LMICs.^[4] Data are available on the performance of qSOFA outside of ICU for diagnosis and mortality prediction of adults with sepsis in LMICs and the results have been contradictory.^[4–7] The performance of qSOFA has shown conflicting results among patients with tropical infections such as malaria, dengue fever, and viral hemorrhagic infection.^[6] As a diagnostic tool, qSOFA has a lower sensitivity in comparison to higher specificity when compared with the other scoring systems.^[7] The diagnostic sensitivity of the qSOFA tool is improved if the pretest probability for sepsis is high. The limitation of qSOFA is that it relies on the clinician’s ability to identify infection as the cause of organ dysfunction, which may be occult early on. Thus, a considerable delay may take place in the process of detection and initiation of interventions. In addition, preexisting diseases may also influence qSOFA measurement. Given the poor sensitivity of the qSOFA the Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock 2021 has strongly recommended against its use as a single screening tool for sepsis or septic shock.^[8]

Parsimonious tools like qSOFA have been developed mainly for non-ICU settings and validated as a risk predictor tool for geographic regions with a high patient burden and in LMICs. Attempts to enhance the prognostic accuracy of qSOFA by the addition of biomarkers like lactate, procalcitonin variables to the tool have been evaluated.^[9] However, this modification of the original instrument will defeat the parsimony purpose of simple bedside qSOFA. In the absence of a gold standard test, making a diagnosis of sepsis should be an iterative process. The combined use of a sensitive SIRS and a specific qSOFA score or a sequential two-step triage approach may be followed to improve the discriminatory capacity in the screening, diagnosis, and prognosis of sepsis in resource-limited settings.