Background

Simple, bedside prediction of infection-related mortality in low-resource settings is crucial for triage and resource-utilisation decisions. We aimed to evaluate mortality prediction by combining point-of-care venous lactate with the quick Sequential Organ Failure Assessment (qSOFA) score in adult patients admitted to hospital with suspected infection in southeast Asia.

Methods

We performed a cohort study by prospectively enrolling patients aged 18 years or older who had been admitted to hospital within the previous 24 h for suspected infection (with at least three documented systemic manifestations of infection according to the 2012 Surviving Sepsis Campaign) at Sunpasitthiprasong Hospital in Ubon Ratchathani, Thailand (derivation cohort). Venous lactate concentration was determined by a point-of-care device and multiple scores were developed. We then evaluated candidate 28-day mortality prediction models combining qSOFA and the lactate scores. A final model was compared with the qSOFA score, a lactate score, and a modified Sequential Organ Failure Assessment (SOFA) score for mortality discrimination using the area under the receiver operating characteristic curve (AUROC). Mortality discrimination of the qSOFA-lactate score was then verified in an external, prospectively enrolled, multinational cohort in southeast Asia.

Findings

Between March 1, 2013, and Jan 26, 2017, 5001 patients were enrolled in the derivation cohort; 4980 had point-of-care lactate data available and were eligible for analysis, and 816 died within 28 days of enrolment. The discrimination for 28-day mortality prediction of a qSOFA-lactate score combining the qSOFA score and a lactate score was superior to that of the qSOFA score alone (AUROC 0·78 [95% CI 0·76–0·80] vs 0·68 [0·67–0·70]; p<0·0001) and similar to a modified SOFA score (0·77 [0·75–0·78]; p=0·088). A lactate score alone had superior discrimination compared with the qSOFA score (AUROC 0·76 [95% CI 0·74–0·78]; p<0·0001). 815 patients were enrolled in the external validation cohort and 792 had point-of-care lactate data and were included in the analysis; the qSOFA-lactate score (AUROC 0·77 [95% CI 0·73–0·82]) showed significantly improved 28-day mortality discrimination compared with the qSOFA score alone (0·69 [0·63–0·74]; p<0·0001).

Interpretation

In southeast Asia, rapid, bedside assessments based on point-of-care lactate concentration combined with the qSOFA score can identify patients at risk of sepsis-related mortality with greater accuracy than the qSOFA score alone, and with similar accuracy to a modified SOFA score.

Funding

National Institutes of Health, Wellcome Trust.

中文翻译：

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在东南亚疑似感染住院患者中结合床旁乳酸和快速顺序器官衰竭评估 (qSOFA) 评分增强床边死亡率预测：一项队列研究

背景

对资源匮乏地区的感染相关死亡率进行简单的床边预测对于分流和资源利用决策至关重要。我们旨在通过将床旁静脉乳酸与快速序贯器官衰竭评估 (qSOFA) 评分相结合来评估东南亚疑似感染住院成人患者的死亡率预测。

方法

我们在 Sunpasitthiprasong 医院前瞻性招募了在过去 24 小时内因疑似感染入院的 18 岁或以上患者（根据 2012 年幸存的脓毒症运动，至少有 3 次记录的全身感染表​​现），我们进行了一项队列研究。乌汶叻差他尼，泰国（衍生队列）。静脉乳酸浓度由护理点设备确定，并开发了多个评分。然后，我们评估了结合 qSOFA 和乳酸评分的候选 28 天死亡率预测模型。使用受试者工作特征曲线下面积 (AUROC) 将最终模型与 qSOFA 评分、乳酸评分和改进的顺序器官衰竭评估 (SOFA) 评分进行死亡率区分。

发现

2013 年 3 月 1 日至 2017 年 1 月 26 日期间，5001 名患者被纳入推导队列；4980 人有即时的乳酸数据可用并有资格进行分析，816 人在入组后 28 天内死亡。qSOFA-乳酸评分结合 qSOFA 评分和乳酸评分对 28 天死亡率预测的区分优于单独的 qSOFA 评分（AUROC 0·78 [95% CI 0·76–0·80] vs0·68 [0·67–0·70]；p<0·0001) 并且类似于修改后的 SOFA 评分 (0·77 [0·75–0·78]; p=0·088)。与 qSOFA 评分相比，单独的乳酸评分具有更高的辨别力（AUROC 0·76 [95% CI 0·74–0·78]；p<0·0001）。815 名患者被纳入外部验证队列，792 名患者有即时乳酸数据并被纳入分析；qSOFA-乳酸评分 (AUROC 0·77 [95% CI 0·73–0·82]) 与单独的 qSOFA 评分 (0·69 [0·63–0·74] ; p<0·0001)。

解释

在东南亚，基于床旁乳酸浓度和 qSOFA 评分的快速床边评估可以比单独使用 qSOFA 评分更准确地识别出有败血症相关死亡风险的患者，并且与改良的 SOFA 评分具有相似的准确性.

资金

美国国立卫生研究院，惠康信托。