Send to

Choose Destination
JAMA. 2018 Jun 5;319(21):2202-2211. doi: 10.1001/jama.2018.6229.

Association of the Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Score With Excess Hospital Mortality in Adults With Suspected Infection in Low- and Middle-Income Countries.

Author information

Department of Medicine and the International Respiratory and Severe Illness Center (INTERSECT), University of Washington, Seattle.
Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Saint Luke Foundation, Port-au-Prince, Haiti.
Department of Anesthesiology, University of Nebraska Medical Center, Omaha.
Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.
Division of Clinical Education and Research, University Teaching Hospital of Kigali, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
Departments of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania.
Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford, United Kingdom.
National Intensive Care Surveillance, Colombo, Sri Lanka.
Intensive Care National Audit & Research Centre, London, United Kingdom.
Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria.
Dev Care Foundation, Dhaka, Bangladesh.
Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone.
College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.
Adult Intensive Care Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
Department of Infectious Diseases, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam.
Ispat General Hospital, Rourkela, Odisha, India.
Center for Emerging Infectious Diseases, Asian Institute of Public Health, Bhubaneswar, Odisha, India.
Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
Division of Pulmonary & Critical Care Medicine and Institute for Global Health, University of Maryland School of Medicine, Baltimore.
Division of Pulmonary & Critical Care Medicine, Atrium Health, Charlotte, North Carolina.
Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana.
Department of Global Biostatistics and Data Science, Tulane University, New Orleans, Louisiana.
Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
University of Gitwe, Gitwe, Rwanda.



The quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score has not been well-evaluated in low- and middle-income countries (LMICs).


To 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 Participants:

Retrospective 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.


Low (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 Measures:

Predictive 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).


The 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 Relevance:

When 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.

[Indexed for MEDLINE]
Free PMC Article

Supplemental Content

Full text links

Icon for Silverchair Information Systems Icon for PubMed Central
Loading ...
Support Center