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Comparison of Diagnostic Accuracies of qSOFA, NEWS, and MEWS to Identify Sepsis in Older Inpatients With Suspected Infection

Published:October 04, 2021DOI:https://doi.org/10.1016/j.jamda.2021.09.005

      Abstract

      Objectives

      To determine and compare the accuracies of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and Modified and National Early Warning Scores (NEWS and MEWS) to identify sepsis in older inpatients with suspected infection.

      Design

      Prospective diagnostic accuracy study.

      Setting and Participants

      Patients admitted to an acute geriatric unit of an Italian University Hospital with at least one sepsis risk factor and suspected infection defined as antibiotic prescription and associated culture test during hospital stay.

      Methods

      Sepsis diagnosis was defined as the presence on discharge documents of International Classification of Diseases, Ninth revision, Clinical Modification codes for severe sepsis, septic shock, or for infection and acute organ disfunction. For each patient, clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, NEWS, and MEWS were derived, and worst scores recorded. Positive cutoffs were set at ≥2, ≥7, and ≥5, respectively. Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and positive and negative likelihood ratios, as well as areas under the receiver operating characteristic curve (AUROCs) were calculated.

      Results

      Among 230 geriatric patients with suspected infection at risk for sepsis (median age 86 years, 49% women), 30.9% had a sepsis diagnosis. A qSOFA ≥2 was recorded in 111 (48.3%) patients, a MEWS ≥5 in 65 (28.3%), and a NEWS ≥7 in 115 (50.0%). The qSOFA showed the highest sensitivity [81.7%, 95% confidence interval (CI) 71.7%–89.5%], but low specificity (66.7%, 95% CI 59.1%–73.7%), resulting in a high NPV (89.1%; 95% CI 82.7%–93.8%) and poor PPV (52.3%, 95% CI 43.0%–61.4%). The AUROC for qSOFA was 0.76 (95% CI 0.69–0.83), comparable with that of NEWS (0.74, 95% CI 0.67–0.81, P = .44), but significantly higher than that of MEWS (0.70, 95% CI 0.63–0.77, P = .04).

      Conclusions and Implications

      Repeated qSOFA determinations are useful to rule out sepsis in geriatric inpatients with suspected infection, but poorly support its diagnosis due to low specificity. More complex MEWS and NEWS do not perform better. Implementation of clinical scores to reliably identify sepsis in older patients is urgently needed.

      Keywords

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      References

        • Singer M.
        • Deutschman C.S.
        • Seymour C.W.
        • et al.
        The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
        JAMA. 2016; 315: 801-810
        • Angus D.C.
        • Linde-Zwirble W.T.
        • Lidicker J.
        • et al.
        Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care.
        Crit Care Med. 2001; 29: 1303-1310
        • Fabbri A.
        • Marchesini G.
        • Benazzi B.
        • et al.
        Old subjects with sepsis in the emergency department: Trend analysis of case fatality rate.
        BMC Geriatr. 2019; 19: 372
        • Lee S.-H.
        • Hsu T.-C.
        • Lee M.-T.G.
        • et al.
        Nationwide trend of sepsis: A comparison among octogenarians, elderly, and young adults.
        Crit Care Med. 2018; 46: 926-934
        • Rowe T.A.
        • McKoy J.M.
        Sepsis in older adults.
        Infect Dis Clin North Am. 2017; 31: 731-742
        • Mankowski R.T.
        • Anton S.D.
        • Ghita G.L.
        • et al.
        Older sepsis survivors suffer persistent disability burden and poor long-term survival.
        J Am Geriatr Soc. 2020; 68: 1962-1969
        • Bouza C.
        • Martínez-Alés G.
        • López-Cuadrado T.
        The impact of dementia on hospital outcomes for elderly patients with sepsis: A population-based study.
        PLoS One. 2019; 14: e0212196
        • Fernando S.M.
        • Guo K.H.
        • Lukasik M.
        • et al.
        Frailty and associated prognosis among older emergency department patients with suspected infection: A prospective, observational cohort study.
        CJEM. 2020; 22: 687-691
        • Abugroun A.
        • Nayyar A.
        • Abdel-Rahman M.
        • Patel P.
        Impact of malnutrition on hospitalization outcomes for older adults admitted for sepsis.
        Am J Med. 2021; 134: 221-226.e1
        • Reyes B.J.
        • Chang J.
        • Vaynberg L.
        • et al.
        Early identification and management of sepsis in nursing facilities: Challenges and opportunities.
        J Am Med Dir Assoc. 2018; 19: 465-471
        • Warmerdam M.
        • Stolwijk F.
        • Boogert A.
        • et al.
        Initial disease severity and quality of care of emergency department sepsis patients who are older or younger than 70 years of age.
        PLoS One. 2017; 12: e0185214
        • Vincent J.L.
        • Moreno R.
        • Takala J.
        • et al.
        The SOFA (Sepsis-related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related Problems of the European Society of intensive care medicine.
        Intensive Care Med. 1996; 22: 707-710
        • Mylotte J.M.
        What is the role of nursing homes in the surviving sepsis campaign?.
        J Am Med Dir Assoc. 2020; 21: 41-45
        • Seymour C.W.
        • Liu V.X.
        • Iwashyna T.J.
        • et al.
        Assessment of clinical criteria for sepsis: For the Third international consensus definitions for sepsis and septic shock (Sepsis-3).
        JAMA. 2016; 315: 762-774
        • Song J.-U.
        • Sin C.K.
        • Park H.K.
        • et al.
        Performance of the quick sequential (sepsis-related) organ failure assessment score as a prognostic tool in infected patients outside the intensive care unit: A systematic review and meta-analysis.
        Crit Care. 2018; 22: 28
        • Askim Å.
        • Moser F.
        • Gustad L.T.
        • et al.
        Poor performance of quick-SOFA (qSOFA) score in predicting severe sepsis and mortality - a prospective study of patients admitted with infection to the emergency department.
        Scand J Trauma Resusc Emerg Med. 2017; 25: 56
        • Churpek M.M.
        • Snyder A.
        • Han X.
        • et al.
        Quick sepsis-related organ failure assessment, systemic inflammatory response syndrome, and early warning scores for detecting clinical deterioration in infected patients outside the intensive care unit.
        Am J Respir Crit Care Med. 2017; 195: 906-911
        • Usman O.A.
        • Usman A.A.
        • Ward M.A.
        Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the emergency department.
        Am J Emerg Med. 2019; 37: 1490-1497
        • Nieves Ortega R.
        • Rosin C.
        • Bingisser R.
        • Nickel C.H.
        Clinical scores and formal triage for screening of sepsis and adverse outcomes on arrival in an emergency department all-comer cohort.
        J Emerg Med. 2019; 57: 453-460.e2
        • Sloane P.D.
        • Ward K.
        • Weber D.J.
        • et al.
        Can sepsis be detected in the nursing home prior to the need for hospital transfer?.
        J Am Med Dir Assoc. 2018; 19: 492-496.e1
        • Kievlan D.R.
        • Zhang L.A.
        • Chang C.-C.H.
        • et al.
        Evaluation of repeated quick sepsis-related organ failure assessment measurements among patients with suspected infection.
        Crit Care Med. 2018; 46: 1906-1913
        • Liu V.X.
        • Lu Y.
        • Carey K.A.
        • et al.
        Comparison of early warning scoring systems for hospitalized patients with and without infection at risk for in-hospital mortality and transfer to the intensive care unit.
        JAMA Netw Open. 2020; 3: e205191
        • Redfern O.C.
        • Smith G.B.
        • Prytherch D.R.
        • et al.
        A comparison of the quick sequential (sepsis-related) organ failure assessment score and the national early warning score in non-ICU patients with/without infection.
        Crit Care Med. 2018; 46: 1923-1933
        • Subbe C.P.
        • Kruger M.
        • Rutherford P.
        • Gemmel L.
        Validation of a modified early warning score in medical admissions.
        QJM. 2001; 94: 521-526
        • Smith G.B.
        • Prytherch D.R.
        • Meredith P.
        • et al.
        The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death.
        Resuscitation. 2013; 84: 465-470
        • Kramer A.A.
        • Sebat F.
        • Lissauer M.
        A review of early warning systems for prompt detection of patients at risk for clinical decline.
        J Trauma Acute Care Surg. 2019; 87: S67-S73
        • Gerry S.
        • Bonnici T.
        • Birks J.
        • et al.
        Early warning scores for detecting deterioration in adult hospital patients: Systematic review and critical appraisal of methodology.
        BMJ. 2020; 369: m1501
        • Royal College of Physicians
        National Early Warning Score (NEWS): Standardising the assessment of acute-illness severity in the NHS. Report of a working party.
        Clin Med (Lond). 2012; 12: 501-503
        • National Institute for Health and Care Excellence (NICE)
        Sepsis: Recognition, diagnosis and early management - NICE guideline 51.
        (Available at:)
        https://www.nice.org.uk/guidance/ng51
        Date: 2017
        Date accessed: June 10, 2021
        • Bossuyt P.M.
        • Reitsma J.B.
        • Bruns D.E.
        • et al.
        STARD 2015: An updated list of essential items for reporting diagnostic accuracy studies.
        BMJ. 2015; 351: h5527
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Katz S.
        • Ford A.B.
        • Moskowitz R.W.
        • et al.
        Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function.
        JAMA. 1963; 185: 914-919
        • Lawton M.P.
        • Brody E.M.
        Assessment of older people: Self-maintaining and instrumental activities of daily living.
        Gerontologist. 1969; 9: 179-186
        • Pfeiffer E.
        A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients.
        J Am Geriatr Soc. 1975; 23: 433-441
        • Teasdale G.
        • Maas A.
        • Lecky F.
        • et al.
        The Glasgow coma scale at 40 years: Standing the test of time.
        Lancet Neurol. 2014; 13: 844-854
        • Giamarellos-Bourboulis E.J.
        • Tsaganos T.
        • Tsangaris I.
        • et al.
        Validation of the new Sepsis-3 definitions: Proposal for improvement in early risk identification.
        Clin Microbiol Infect. 2017; 23: 104-109
        • Dorsett M.
        • Kroll M.
        • Smith C.S.
        • et al.
        qSOFA has poor sensitivity for prehospital identification of severe sepsis and septic shock.
        Prehosp Emerg Care. 2017; 21: 489-497
        • Freund Y.
        • Lemachatti N.
        • Krastinova E.
        • et al.
        Prognostic accuracy of Sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department.
        JAMA. 2017; 317: 301-308
        • Haydar S.
        • Spanier M.
        • Weems P.
        • et al.
        Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis.
        Am J Emerg Med. 2017; 35: 1730-1733
        • Ballester L.
        • Martínez R.
        • Méndez J.
        • et al.
        Differences in hypotensive vs. non-hypotensive sepsis management in the emergency department: Door-to-antibiotic time impact on sepsis survival.
        Med Sci (Basel). 2018; 6: E91
        • Smith G.B.
        • Redfern O.C.
        • Pimentel M.A.
        • et al.
        The national early warning score 2 (NEWS2).
        Clin Med (Lond). 2019; 19: 260
        • Churpek M.M.
        • Yuen T.C.
        • Winslow C.
        • et al.
        Differences in vital signs between elderly and nonelderly patients prior to ward cardiac arrest.
        Crit Care Med. 2015; 43: 816-822
        • de Groot B.
        • Stolwijk F.
        • Warmerdam M.
        • et al.
        The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: An observational multi-centre study.
        Scand J Trauma Resusc Emerg Med. 2017; 25: 91
        • Minnesota Hospital Association
        Seeing sepsis - long term care - early sepsis identification saves lives.
        (Available at:)
        • Lagu T.
        • Rothberg M.B.
        • Shieh M.-S.
        • et al.
        What is the best method for estimating the burden of severe sepsis in the United States?.
        J Crit Care. 2012; 27: 414.e1-414.e9
        • Devia Jaramillo G.
        • Ibáñez Pinilla M.
        Quick sequential organ failure assessment, sequential organ failure assessment, and procalcitonin for early diagnosis and prediction of death in elderly patients with suspicion of sepsis in the emergency department, based on Sepsis-3 definition.
        Gerontology. 2022; 68: 171-180

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