Background
Methods
Setting and design of the study
Study cohort
Data collection
Definition of co-morbidities
Outcome variables
Statistical analyses
Results
Characteristics of the study cohort
Characteristic | Entire cohort | Non-survivors | Survivors |
P value | Hospitalised | Non-hospitalised |
P value | ICU admission | Non-ICU admission |
P value |
---|---|---|---|---|---|---|---|---|---|---|
Number of patients | 1641 | 547 | 1094 | 861 | 780 | 246 | 1395 | |||
Age, years | 73 (62–79) | 75 (66–81) | 73 (60–78) | <0.001 | 74 (65–80) | 72 (59–78) | <0.001 | 75 (68–81) | 73 (61–79) | <0.001 |
Male sex, % | 59 | 58 | 59 | 0.48 | 57 | 61 | 0.12 | 57 | 59 | 0.61 |
Co-morbidities, % | ||||||||||
COPD | 34 | 36 | 32 | 0.10 | 36 | 31 | 0.01 | 43 | 32 | 0.001 |
CVD | 28 | 30 | 26 | 0.07 | 30 | 26 | 0.13 | 30 | 27 | 0.33 |
Stroke | 12 | 14 | 11 | 0.08 | 12 | 12 | 0.79 | 13 | 12 | 0.66 |
Tumour | 9 | 11 | 8 | 0.04 | 10 | 8 | 0.16 | 11 | 9 | 0.32 |
Renal | 5 | 6 | 4 | 0.08 | 6 | 4 | 0.22 | 7 | 5 | 0.26 |
Liver | 8 | 9 | 8 | 0.25 | 8 | 8 | 0.62 | 10 | 8 | 0.19 |
DM | 15 | 13 | 16 | 0.13 | 17 | 14 | 0.06 | 17 | 15 | 0.38 |
Vital signs | ||||||||||
MAP, mmHg | 80 (67–93) | 70 (54–83) | 84 (73–97) | <0.001 | 77 (60–90) | 83 (71–97) | <0.001 | 67 (50–82) | 82 (70–95) | <0.001 |
Respiratory rate, breaths/minute | 27 (24–32) | 28 (24–32) | 26 (24–32) | 0.01 | 28 (24–32) | 26 (24–32) | 0.09 | 30 (24–32) | 26 (24–32) | 0.003 |
Temperature, °C | 36.8 (36.2–38.2) | 36.8 (36.2–38.2) | 36.8 (36.2–38.1) | 0.83 | 36.8 (36.2–38.2) | 36.8 (36.2–38.1) | 0.65 | 37 (36.2–38.2) | 36.8 (36.2–38.1) | 0.62 |
Heart rate, beats/minute | 110 (98–126) | 110 (99–126) | 110 (97–125) | 0.20 | 110 (98–128) | 110 (98–124) | 0.22 | 110 (98–126) | 110 (98–126) | 0.99 |
Mental confusion, % | 28 | 46 | 20 | <0.001 | 37 | 19 | <0.001 | 66 | 22 | <0.001 |
Laboratory results | ||||||||||
WBC, ×109/L | 11.2 (7.7–15.6) | 11.0 (7.6–15.1) | 11.2 (7.8–15.6) | 0.48 | 11.2 (7.7–15.5) | 11.3 (7.7–15.7) | 0.75 | 11.4 (7.6–16) | 11.2 (7.7–15.5) | 0.71 |
PCT, ng/ml | 1.1 (0.9–3.4) | 1.3 (0.9–9.4) | 1.1 (0.9–3.4) | <0.001 | 1.1 (0.9–3.4) | 1.1 (0.9–3.4) | 0.50 | 1.2 (0.9–3.7) | 1.1 (0.9–3.4) | 0.15 |
PaO2, mmHg | 75 (59–94) | 71 (57–89) | 77 (60–96) | <0.001 | 74 (59–92) | 76 (59–96) | 0.28 | 69 (55–86) | 77 (60–95) | <0.001 |
Platelets, ×109/L | 184 (135–243) | 185 (136–243) | 183 (134–244) | 0.91 | 186 (136–243) | 183 (134–243) | 0.81 | 188 (142–246) | 183 (134–242) | 0.73 |
Creatinine, μmol/L | 100 (75–148) | 106 (78–170) | 98 (74–136) | <0.001 | 102 (77–157) | 98 (73–136) | 0.02 | 134 (98–228) | 96 (72–134) | <0.001 |
Bilirubin, μmol/L | 12.3 (8.3–18.6) | 13.1 (8.1–19.3) | 12.0 (8.1–18.3) | 0.04 | 12.2 (8.2–19) | 12.5 (8.3–18.3) | 0.94 | 12.2 (8.2–18.7) | 12.3 (8.3–18.5) | 0.63 |
Positive sputum culture | 378/1132 (33 %) | 143/394 (36 %) | 235/738 (32 %) | 0.13 | 209/583 (36 %) | 169/549 (31 %) | 0.07 | 73/187 (39 %) | 305/945 (32 %) | 0.07 |
Lactate, mmol/L | 2.6 (1.0–5.1) | 5.4 (3.1–8.1) | 1.6 (0.8–3.3) | <0.001 | 4.4 (2.5–7.0) | 1.2 (0.6–2.5) | <0.001 | 8.5 (6.6–11.7) | 2.1 (0.9–4.0) | <0.001 |
Multi-lobar opacities, % | 40 | 47 | 37 | <0.001 | 42 | 38 | 0.07 | 53 | 38 | <0.001 |
PSI | 124 ± 40 (n = 578) | 144 ± 36 (n = 199) | 113 ± 38 (n = 379) | <0.001 | 137 ± 38 (n = 278) | 111 ± 38 (n = 300) | <0.001 | 156 ± 37 (n = 92) | 117 ± 38 (n = 486) | <0.001 |
APACHE II | 16 (12–21) | 20 (15–26) | 15 (11–19) | <0.001 | 18 (14–23) | 15 (11–18) | <0.001 | 22 (17–28) | 16 (11–20) | <0.001 |
CRB-65 | 2 (1–2) | 2 (1–3) | 1 (1–2) | <0.001 | 2 (1–2) | 1 (1–2) | <0.001 | 2 (2–3) | 1 (1–2) | <0.001 |
CRB | 1 (0–1) | 1 (1–2) | 1 (0–1) | <0.001 | 1 (0–2) | 1 (0–1) | <0.001 | 1 (1–2) | 1 (0–1) | <0.001 |
qSOFA | 1 (1–2) | 2 (1–2) | 1 (1–1) | <0.001 | 1 (1–2) | 1 (1–2) | <0.001 | 2 (1–2) | 1 (1–2) | <0.001 |
28-day mortality (%) | 33 | – | – | – | 54 | 11 | <0.001 | 85 | 24 | <0.001 |
CRB-65, CRB and qSOFA scores and illness severity
Baseline risk
95 % CI for OR | |||||||||
---|---|---|---|---|---|---|---|---|---|
Outcome | Predictor | β coefficient | SE | Wald statistic |
P value | OR | 5 % | 95 % | |
Without qSOFA | 28-day mortality | Age | 0.024 | 0.004 | 34.321 | <0.001 | 1.025 | 1.016 | 1.033 |
Tumour | 0.322 | 0.176 | 3.348 | 0.067 | 0.381 | 0.977 | 1.950 | ||
Constant | −2.448 | 0.303 | 65.404 | <0.001 | 0.086 | ||||
Hospitalisation | Age | 0.02 | 0.004 | 29.235 | <0.001 | 1.02 | 1.013 | 1.027 | |
COPD | 0.232 | 0.106 | 4.756 | 0.029 | 1.261 | 1.024 | 1.552 | ||
Constant | −1.355 | 0.261 | 26.962 | <0.001 | 0.258 | ||||
ICU admission | Age | 0.024 | 0.006 | 17.357 | <0.001 | 1.024 | 1.013 | 1.036 | |
COPD | 0.441 | 0.142 | 9.65 | 0.002 | 1.554 | 1.177 | 2.053 | ||
Constant | −3.625 | 0.431 | 70.61 | <0.001 | 0.027 | ||||
With qSOFA | 28-day mortality | Age | 0.024 | 0.004 | 29.473 | <0.001 | 1.024 | 1.015 | 1.033 |
Tumour | 0.085 | 0.187 | 0.207 | 0.649 | 1.089 | 0.754 | 1.572 | ||
qSOFA | 0.939 | 0.086 | 119.637 | <0.001 | 2.557 | 2.161 | 3.025 | ||
Constant | −3.686 | 0.34 | 117.299 | <0.001 | 0.025 | ||||
Hospitalisation | Age | 0.019 | 0.004 | 25.521 | <0.001 | 1.019 | 1.012 | 1.026 | |
COPD | 0.195 | 0.108 | 3.264 | 0.071 | 1.215 | 0.984 | 1.501 | ||
qSOFA | 0.522 | 0.079 | 43.73 | <0.001 | 1.686 | 1.444 | 1.968 | ||
Constant | −1.971 | 0.282 | 48.767 | <0.001 | 0.139 | ||||
ICU admission | Age | 0.023 | 0.006 | 14.252 | <0.001 | 1.023 | 1.011 | 1.035 | |
COPD | 0.358 | 0.147 | 5.921 | 0.015 | 1.431 | 1.072 | 1.91 | ||
qSOFA | 0.939 | 0.102 | 84.913 | <0.001 | 2.557 | 2.094 | 3.122 | ||
Constant | −4.881 | 0.471 | 107.292 | <0.001 | 0.008 |
Predictive performance of the baseline risk model, CRB-65, CRB and qSOFA
95 % CI | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Outcomes | Predictors | Cut-off value | Sensitivity | Specificity | PPV | NPV | LR+
| LR−
| OR | 5 % | 95 % |
Mortality | CRB-65 | ≤1 | 70 % | 57 % | 45 % | 79 % | 1.6 | 0.5 | 3.059 | 2.459 | 3.804 |
CRB-65 | 2 | 30 % | 88 % | 55 % | 72 % | 2.5 | 0.8 | 3.120 | 2.409 | 4.041 | |
CRB-65 | ≥3 | 7 % | 98 % | 60 % | 68 % | 3.5 | 1.0 | 3.141 | 1.854 | 5.321 | |
CRB | ≤1 | 36 % | 81 % | 51 % | 70 % | 1.9 | 0.8 | 2.442 | 1.927 | 3.094 | |
CRB | 2 | 9 % | 97 % | 62 % | 66 % | 3.0 | 0.9 | 3.201 | 1.994 | 5.139 | |
qSOFA | ≤1 | 53 % | 75 % | 52 % | 76 % | 2.1 | 0.6 | 3.418 | 2.752 | 4.246 | |
qSOFA | 2 | 12 % | 97 % | 68 % | 69 % | 4.0 | 0.9 | 4.783 | 3.063 | 7.469 | |
Hospitalisation | CRB-65 | ≤1 | 59 % | 56 % | 60 % | 55 % | 1.3 | 0.7 | 1.807 | 1.485 | 2.198 |
CRB-65 | 2 | 22 % | 86 % | 63 % | 50 % | 1.6 | 0.9 | 1.715 | 1.322 | 2.224 | |
CRB-65 | ≥3 | 5 % | 97 % | 67 % | 48 % | 1.7 | 1.0 | 1.851 | 1.073 | 3.195 | |
CRB | ≤1 | 27 % | 81 % | 62 % | 50 % | 1.4 | 0.9 | 1.630 | 1.290 | 2.060 | |
CRB | 2 | 6 % | 97 % | 69 % | 48 % | 2.0 | 1.0 | 2.066 | 1.263 | 3.381 | |
qSOFA | ≤1 | 42 % | 74 % | 64 % | 53 % | 1.6 | 0.8 | 2.006 | 1.627 | 2.473 | |
qSOFA | 2 | 8 % | 97 % | 74 % | 49 % | 2.7 | 1.0 | 2.673 | 1.675 | 4.265 | |
ICU admission | CRB-65 | ≤1 | 76 % | 53 % | 22 % | 93 % | 1.6 | 0.5 | 3.589 | 2.626 | 4.906 |
CRB-65 | 2 | 38 % | 86 % | 32 % | 89 % | 2.7 | 0.7 | 3.611 | 2.681 | 4.864 | |
CRB-65 | ≥3 | 14 % | 98 % | 57 % | 87 % | 7.0 | 0.9 | 8.444 | 4.967 | 14.357 | |
CRB | ≤1 | 45 % | 81 % | 29 % | 89 % | 2.4 | 0.7 | 3.426 | 2.579 | 4.552 | |
CRB | 2 | 15 % | 97 % | 49 % | 87 % | 5.0 | 0.9 | 6.352 | 3.970 | 10.163 | |
qSOFA | ≤1 | 60 % | 70 % | 26 % | 91 % | 2.0 | 0.6 | 3.554 | 2.687 | 4.702 | |
qSOFA | 2 | 18 % | 96 % | 45 % | 87 % | 4.5 | 0.9 | 5.471 | 3.558 | 8.411 |
Prevalence of outcomes according to CRB-65, CRB and qSOFA scores
Score | |||||
---|---|---|---|---|---|
0 | 1 | 2 | 3 | 4 | |
Number of patients | |||||
qSOFA | 86 | 991 | 469 | 95 | – |
CRB-65 | 165 | 626 | 556 | 234 | 60 |
CRB | 582 | 678 | 304 | 77 | – |
28-day mortality, n (%) | |||||
qSOFA | 14 (16.3) | 242 (24.4)a
| 226 (48.2)a
| 65 (68.4) | – |
CRB-65 | 28 (17.0) | 138 (22.0) a
| 218 (39.2)a,b
| 127 (54.3)b
| 36 (60.0) |
CRB | 111 (19.1)a
| 240 (35.4)a,b
| 148 (48.7)c
| 48 (62.3) | – |
Hospitalization, n (%) | |||||
qSOFA | 32 (37.2) | 470 (47.4)a
| 289 (61.6)c
| 70 (73.7) | – |
CRB-65 | 46 (27.9)a
| 309 (49.4)a
| 320 (57.6) | 146 (62.4) | 40 (66.7) |
CRB | 257 (44.2)a
| 369 (54.4)b
| 182 (59.9) | 53 (68.8) | – |
ICU admission, n (%) | |||||
qSOFA | 8 (9.3) | 90 (9.1)a
| 105 (22.4)a
| 43 (45.3) | – |
CRB-65 | 13 (7.9) | 45 (7.2)a
| 95 (17.1)a,b
| 59 (25.2)a,b
| 34 (56.7) |
CRB | 40 (6.9)a
| 95 (14.0)a,b
| 73 (24.0)a
| 38 (49.4) | – |
Discussion
Limitations
Conclusions
Key messages
-
qSOFA criteria were respiratory rate ≥22 breaths/minute, altered mentation (Glasgow Coma Scale score ≤13 in the original study or <15 in the definitions for sepsis and septic shock set by the Third International Consensus) and systolic blood pressure ≤100 mmHg.
-
In the present study, patients with qSOFA scores of 0, 1, 2 and 3 had, respectively, mortality of 16.3 %, 24.4 %, 48.2 % and 68.4 %; prevalence of hospitalisation of 37.2 %, 47.4 %, 61.6 % and 73.7 %; and prevalence of ICU admission of 9.3 %, 9.1 %, 22.4 % and 45.3 %.
-
qSOFA provided additional value above baseline risk in predicting mortality and requirement for ICU admission.
-
AUC values of qSOFA for prediction of mortality, hospitalisation and ICU admission were similar to those of CRB-65 in patients with pneumonia in the ED.
-
qSOFA provided better performance than CRB-65 for distinguishing a high risk of mortality and requirement for ICU admission in patients with pneumonia in the ED.