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Supplementary Online Content Rudd KE, Seymour CW, Aluisio AR, et al; Sepsis Assessment and Identification in Low Resource Settings (SAILORS) Collaboration. 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. JAMA. doi:10.1001/jama.2018.6229 eMethods. Description of Cohorts eTable 1. Regulatory Approval by Cohort eTable 2. Missingness of Variables in the Individual and Combined Cohorts eTable 3. Risk Ratio for Hospital Mortality Comparing Encounters With 2 vs <2 qSOFA Points and 2 vs <2 SIRS Criteria Among Patients With Suspected Infection by Individual Cohort eTable 4. Odds Ratio for Hospital Mortality Comparing Encounters With 2 vs <2 qSOFA Points and 2 vs <2 SIRS Criteria Among Patients With Suspected Infection by Quartile of Baseline Risk for Hospital Mortality in the Combined Cohort eTable 5. Incremental Discrimination of qSOFA Score or SIRS Criteria Added to Baseline Risk Model For Hospital Mortality Among Patients With Suspected Infection in the Individual and Combined Cohorts eTable 6. Incremental Discrimination of qSOFA Score or SIRS Criteria Added to Baseline Risk Model For Hospital Mortality Among Patients With Suspected Infection in the Individual and Combined Cohorts, by HIV Status and Infection Type eTable 7. Predictive Validity of qSOFA Score and SIRS Criteria in the Combined Cohort, Sensitivity Analyses eTable 8. Mortality Prediction of qSOFA Score and SIRS Criteria in the Individual and Combined Cohorts eFigure 1. Distribution of Patients by qSOFA Score and SIRS Criteria Among Patients With Suspected Infection in the Individual Cohorts eFigure 2. Observed Mortality by qSOFA Score and SIRS Criteria Among Patients With Suspected Infection in the Individual Cohorts eFigure 3. Risk Ratio for Hospital Mortality (Log-Scale) Comparing Encounters With Moderate (1) and High (2) vs Low (0) qSOFA Score and SIRS Criteria Among Patients With Suspected Infection by Individual Cohort (A) and Odds Ratio for Hospital Mortality (Log-Scale) Comparing Encounters with Moderate (1) and High (2) vs Low (0) qSOFA Score and SIRS Criteria Among Patients With Suspected Infection by Quartile of Baseline Risk for Hospital Mortality in the Combined Cohort (B) eFigure 4. Receiver Operating Characteristic Curves for qSOFA Score or SIRS Criteria Added to Baseline Risk Model for Hospital Mortality Among Patients With Suspected Infection in the Individual Cohorts eFigure 5. Odds Ratio for Hospital Mortality (Log-Scale) Comparing Encounters With 2 vs <2 qSOFA Points and 2 vs <2 SIRS Criteria Among Patients With Suspected Infection, by HIV Status and Infection Type eFigure 6. Discrimination of qSOFA Score or SIRS Criteria Added to Baseline Risk Model for Hospital Mortality Among Patients With Suspected Infection, by HIV Status and Infection Type eReferences This supplementary material has been provided by the authors to give readers additional information about their work.

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eMethods. Description of Cohorts The cohorts included in our study represent a diverse set of nine datasets: eight cohort studies (five prospective and three retrospective) and one randomized clinical trial. These studies, with a combined total of 6,569 adult patients, were conducted in a variety of settings across sub-Saharan Africa, Asia, and the Americas. Patients were recruited to the cohorts from a range of hospital settings, including small community hospitals, military hospitals, rural regional hospitals, national referral hospitals, and specialty infectious disease hospitals. Cohorts included primarily medical patients enrolled from the emergency department (ED), hospital ward, or intensive care unit (ICU). Each cohort is described below. 1. Evaluation of Emergency Care Delivery and Patient Outcomes in Kigali, Rwanda

(Kigali): This is a retrospective cohort study performed at the University Teaching Hospital of Kigali in Kigali, Rwanda.1 This site is the primary public referral center for healthcare in Rwanda and is a tertiary-care institution with approximately 500 inpatient beds. Patients age ≥15 years presenting to the ED for care between January1 and December 31, 2013 with a final ED diagnosis of a suspected infection were included. Of the 760 patients in the original cohort, 302 met SAILORS inclusion criteria.

2. The 'Bekele Afessa Scan-Teach-Treat Approach' to Improve Care of Patients with Acute Infection at the Gitwe Hospital/Rwanda (Gitwe): This is a single-center prospective before-and-after study conducted at Gitwe District Hospital in Rwanda March 2016 - March 2017, in collaboration with the Surviving Sepsis Campaign Task Force to Improve Sepsis in Resource-Limited Settings. The site is a public referral hospital. Patients age >28 days with a diagnosis of suspected acute infection were enrolled from the ED (SAILORS analysis included those >18 years only; 1026 patients aged 0-18 years and 7 patients with age not recorded were excluded from SAILORS analysis).

3. International Collaboration for Infectious Disease Research on Lassa fever and Ebola

(Suspected Lassa): This is a prospective, observational, consecutively enrolled cohort study of patients age ≥15 years at Kenema Government Hospital in Sierra Leone with suspected Lassa Fever.2 The patients were enrolled from 2012-2016. The patients met the World Health Organization (WHO) case definition of suspected Lassa Fever, and were all admitted to the hospital’s specialized Lassa Fever Ward at the time of study recruitment.

4. Haiti-RELIC 1: This is a retrospective cohort study performed at St. Luke Family Hospital in Port-au-Prince, Haiti. 3 This is an 80-bed faith-based community hospital, and facilities at the time of the study included an ED, 6-bed ICU, outpatient clinics, two operating theaters, three inpatient medicine wards, and a cholera ward. The study enrolled all patients age ≥17 years evaluated in the ED from January-March 2012, with the three-month time period overlapping both the Haitian dry and rainy seasons.

5. Haiti-RELIC 2: This is a retrospective cohort study performed at St. Luke Family Hospital in Port-au-Prince, Haiti.4 This was a follow-up study to Haiti-RELIC 1 (described above), and enrolled ED patients age ≥17 years meeting modified WHO Integrated Management of Adult Illness District Clinician Manual systemic inflammatory response syndrome (SIRS) criteria from February-April 2014. These criteria included any two of the following: heart rate ≥100 beats per minute, respiratory rate ≥24 breaths per minute, or temperature <36 degrees or ≥38 degrees Centigrade.5 This study was designed to evaluate the impact of a sepsis quality improvement program that the hospital implemented in January 2014. This protocol



recommended fluid resuscitation approach, point-of-care lactate measurement, optional inferior vena cava measurement by ultrasound, and routine vital signs documentation.

6. Ubon-Sepsis: This is a prospective cohort study of patients 18 years old with community-acquired infection at Sunpasitthiprasong Hospital in Ubon Ratchathani, Thailand.6 This is a large public tertiary-care hospital with over 1,400 inpatient beds. Patients included in the SAILORS analysis were enrolled from the ED, medical acute care wards, or medical ICUs March 2013-February 2014. Patients were admitted with a primary diagnosis of infection made by the attending physician, were within 24 hours of admission to the study hospital, and had at least three Surviving Sepsis Campaign criteria for sepsis documented in the medical record.7 Patients were excluded if they were diagnosed with hospital-acquired infections, had a previous hospitalization within the past 30 days, or were transferred from other hospitals with a total duration of hospitalization >72 hours. Initial study nurse evaluation included Glasgow coma scale (GCS) assessment.

7. South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT): This is a multicenter, open-label, randomized controlled trial in patients admitted to the hospital with severe falciparum malaria in Bangladesh, India, Indonesia, and Myanmar.8 Patients >2 years of age were enrolled June 2003-Mary 2005, and assigned to receive intravenous artesunate or intravenous quinine. Only those 18 years were included in SAILORS (313 patients aged <18 years were excluded from analysis).

8. Vietnam: This is a prospective cohort study conducted at the Hospital for Tropical Diseases

in Ho Chi Minh City, Vietnam November 2014-January 2016.9 The study enrolled adult patients, defined as those aged 15 years, within 48 hours of ICU admission. Patients with a previous ICU admission within the past 90 days were excluded. The hospital is a tertiary referral hospital for infectious diseases that serves Southern Vietnam. Patients with documented tetanus as their primary infection were excluded from SAILORS analysis (215 patients).

9. Evaluation of the Feasibility and Performance of Existing Early Warning Scores to Identify Patients at Risk of Adverse Outcomes in an LMIC Setting (Sri Lanka): This is a prospective cohort study conducted from May to December 2015 in Moneragala District General Hospital, a public hospital in Sri Lanka.10 Those patients 18 years old admitted to the acute care wards with suspected infection based on ICD-10 diagnosis code were included in the analysis.



eTable 1. Regulatory Approval by Cohort

Cohort Regulatory Bodies Kigali1 University Teaching Hospital – Kigali (Rwanda), Lifespan – Rhode Island Hospital

(United States) Gitwe Rwanda National Ethics Committee (Rwanda), University of Nebraska Medical Center

(United States) Suspected Lassa2

Sierra Leone Ethics and Scientific Review Committee (Sierra Leone), Tulane University (United States)

Haiti-RELIC 13 St. Luke Hospital (Haiti), University of Maryland (United States) Haiti-RELIC 24 St. Luke Hospital (Haiti), University of Maryland (United States) Ubon-Sepsis6 Mahidol University Faculty of Tropical Medicine Ethics Committee (Thailand), University

of Washington (United States), Oxford University Tropical Research Ethics Committee (United Kingdom), Sunpasitthiprasong Hospital (Thailand)

SEAQUAMAT8 Local or national IRB approval was obtained for all SEAQUAMAT sites: Chittagong Medical College Hospital (Bangladesh), North Oakkalapa General Hospital (Myanmar), Thaton District Hospital (Myanmar), Defense Services General Hospital (Myanmar), Myitkyina General Hospital (Myanmar), No 1 Military Hospital (Myanmar), Lashio Hospital (Myanmar), Taungoo General Hospital (Myanmar), Ispat Hospital (India), RS Mitra Masyarakat Hospital (Indonesia); Oxford University Tropical Research Ethics Committee (United Kingdom)

Vietnam9 Scientific and Ethical Committee of Hospital for Tropical Diseases (Vietnam), Oxford University Tropical Research Ethics Committee (United Kingdom)

Sri Lanka10 University of Colombo (Sri Lanka)



eTable 2. Missingness of Variables in the Individual and Combined Cohorts

Variable, No. Missing (%)

Kigali1 N = 302

Gitwe N = 561

Suspected Lassa2 N = 540

Haiti-RELIC 13 N = 156

Haiti-RELIC 24 N = 105

Ubon-Sepsis6 N = 1210

SEAQUAMAT8 N = 1148

Vietnam9 N = 624

Sri Lanka10 N= 1923

Combined Cohort N=6,569

Age 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 5 (4.8) 0 (0.0) 0 (0.0) 0 (0.0) 6 (0.3) 11 (0.2) Sex 0 (0.0) 6 (1.1) 2 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 3 (0.2) 11 (0.2) HIV status 0 (0.0) 411 (73) 540 (100) 134 (86) 0 (0) 1 (0.08) 1148 (100) 1 (0.2) 1923 (100) 4158 (63) Infection typea Malaria 0 (0.0) 0 (0.0) 540 (100) 0 (0.0) 0 (0.0) 0 (0.0) 2 (0.2) 0 (0.0) 0 (0.0) 542 (8.3) Dengue 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Pneumonia 0 (0.0) 0 (0.0) 540 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 540 (8.2) Tuberculosis 0 (0.0) 0 (0.0) 540 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 540 (8.2) Transfer status 0 (0.0) 561 (100) 540 (100) 0 (0.0) 0 (0.0) 2 (0.2) 1148 (100) 0 (0.0) 1923 (100) 4174 (64) qSOFA and SIRS components

Temperature 54 (18) 13 (2.3) 26 (4.8) 42 (27) 0 (0.0) 0 (0.0) 2 (0.2) 49 (7.9) 99 (5.2) 285 (4.3) Heart rate 30 (9.9) 6 (1.1) 29 (5.4) 39 (25) 0 (0.0) 11 (0.9) 1148 (100) 56 (9.0) 69 (3.6) 1388 (21) White blood cell count 250 (83) 141 (25) 354 (66) 143 (92) 64 (61) 8 (0.7) 1148 (100) 0 (0.0) 1923 (100) 4031 (61) Immature bands 302 (100) 561 (100) 540 (100) 156 (100) 105 (100) 34 (2.8) 1148 (100) 624 (100) 1923 (100) 5393 (82) Respiratory rate 39 (13) 14 (2.5) 31 (5.7) 55 (35) 4 (3.8) 323 (27) 2 (0.2) 53 (8.5) 101 (5.3) 622 (9.5) GCS or AVPU 62 (21)b 5 (0.9)c 512 (95) 156 (100)d 96 (91)d 0 (0.0) 0 (0.0) 0 (0.0) 498 (26)c 1329 (20) SBP 30 (9.9) 14 (2.5) 59 (11) 39 (25) 2 (1.9) 1 (0.1) 10 (0.9) 59 (9.5) 89 (4.6) 303 (4.6) Hospital mortality 0 (0.0) 3 (0.5) 324 (60) 9 (5.8) 1 (1.0) 0 (0.0) 14 (1.2) 0 (0.0) 0 (0.0) 351 (5.3) Abbreviations: SIRS, systemic inflammatory response syndrome; qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SBP, systolic blood pressure; AVPU, alert verbal pain unresponsive scale; GCS, Glasgow coma scale a Infection type was preferentially classified according to lab-confirmed diagnosis. When this was unavailable or inapplicable, patients were classified according to discharge diagnosis or, lastly, according to admission diagnosis. b GCS was recorded for 224 (74%) patients, and AVPU was recorded for an additional 16 (5.3%) patients c GCS was not recorded for any patients and AVPU was substituted

d GCS was not recorded in Haiti-Relic 1 and was recorded in only 9% of patients in Haiti-Relic 2. Emergency Department Attending physician diagnosis of encephalopathy was considered to fulfill criteria for altered mental status for 19 (12%) patients in Haiti-Relic 1 and 3 (2.9%) additional patients in Haiti-Relic 2.



eTable 3. Risk Ratio for Hospital Mortality Comparing Encounters With 2 vs <2 qSOFA Points and 2 vs <2 SIRS Criteria Among Patients With Suspected Infection by Individual Cohort

qSOFA Score

SIRS Criteria

Cohort

Hospital Mortality

Deaths / Total (%),

2 qSOFA Points

Hospital Mortality

Deaths / Total (%),

<2 qSOFA Points

Hospital Mortality Absolute

Difference [95% CI], 2 vs <2 qSOFA Points

Risk Ratio [95% CI], qSOFA Score

Hospital Mortality

Deaths / Total (%),

2 SIRS Criteria

Hospital Mortality

Deaths / Total (%),

<2 SIRS Criteria


Difference [95% CI], 2 vs <2

SIRS Criteria

Risk Ratio [95% CI],

SIRS Criteria

Kigali1 15/62 (24%) 51/240 (21%) 3% [-9-15%] 1.1 [0.7-1.9] 35/1038 (25%) 31/14 (19%) 6% [-3-

16%] 1.3 [0.9-2.1]

Gitwe 16/106 (15%) 22/452 (5%) 10% [3-

17%] 3.1 [1.7-5.7] 27/177 (10%) 11/281 (4%) 6% [2-10%] 2.5 [1.3-4.9] Suspected Lassa2 48/104 (46%) 37/112 (33%)

13% [0.2-26%] 1.4 [1.0-2.0] 64/146 (44%) 21/70 (30%)

14% [0.4-27%] 1.5 [1.0-2.2]

Haiti-RELIC 13 19/47 (40%) 9/100 (9%) 31% [16-

47%] 4.5 [2.2-9.2] 23/84 (27%) 5/63 (8%) 19% [8-

31%] 3.5 [1.4-8.6]

Haiti-RELIC 24 9/54 (17%) 2/50 (4%) 13% [1-

24%] 4.2 [0.9-18] 11/103 (11%) 0/1 (0%) 11% [5-

17%] 1.0 [1.0-1.0]

Ubon-Sepsis6 59/592 (10%) 31/618 (5%) 5% [2-8%] 2.0 [1.3-3.0] 81/1095 (7%) 9/115 (8%) -0.4% [-6-

5%] 0.9 [0.5-1.8]

SEAQUAMAT8 174/735 (24%) 44/399 (11%) 13% [8-

17%] 2.1 [1.6-2.9] 72/385 (19%) 146/749 (19%) -1% [-6-

4%] 1.0 [0.7-1.2]

Vietnam9 48/200 (24%) 35/424 (8%) 16% [9-

22%] 2.9 [1.9-4.3] 55/321 (17%) 28/303 (9%) 8% [3-13%] 1.9 [1.2-2.8]

Sri Lanka10 11/254 (4%) 13/1669

(0.8%) 4% [1-6%] 5.6 [2.5-12] 9/387 (2%) 15/1536 (1%) 1% [-0.2-

3%] 2.4 [1.1-5.4] Abbreviations: SIRS, systemic inflammatory response syndrome; qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment



eTable 4. Odds Ratio for Hospital Mortality Comparing Encounters With 2 vs <2 qSOFA Points and 2 vs <2 SIRS Criteria Among Patients With Suspected Infection by Quartile of Baseline Risk for Hospital Mortality in the Combined Cohort

qSOFA Score

SIRS Criteria

Cohort

Hospital Mortality Deaths /

Total (%), 2 qSOFA

Points


Total (%), <2 qSOFA

Points


Difference [95% CI], 2 vs <2 qSOFA Points

Odds Ratio [95% CI], qSOFA Score


Total (%), 2 SIRS Criteria


Total (%), <2 SIRS Criteria


Difference [95% CI], 2 vs <2

SIRS Criteria

Odds Ratio [95% CI],

SIRS Criteria

Combined Cohorts, Quartile of Baseline Risk, Baseline Risk Mean [Range]

Quartile 1 12% [10-13%]

99/583 (17%)

43/938 (5%) 12% [9-16%] 4.3 [2.9-6.3]

81/628 (13%)

61/893 (7%) 6% [3-9%] 2.0 [1.4-2.9]

Quartile 2 14% [13-16%]

78/461 (17%)

44/1021 (4%) 13% [9-16%] 4.5 [3.0-6.8]

54/556 (10%)

68/926 (7%) 2% [-1-5%] 1.4 [0.9-2.0]

Quartile 3 18% [16-20%]

89/458 (19%)

56/1117 (5%) 14% [11-18%] 4.6 [3.2-6.6]

76/691 (11%)

69/884 (8%) 3% [0.2-6%] 1.5 [1.0-2.1]

Quartile 4 25% [20-47%]

132/645 (20%)

101/977 (10%) 10% [6-14%] 2.2 [1.7-3.0]

166/1050 (16%)

67/572 (12%) 4% [1-8%] 1.4 [1.0-1.9]

Combined Cohorts, Overall

399/2154

(19%)

244/4064

(6%)

13% [11-14%]

3.6 [3.0-4.2]

377/2936

(13%)

266/3282

(8%)

5% [3-6%]

1.7 [1.4-2.0]

Abbreviations: SIRS, systemic inflammatory response syndrome; qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment. Baseline risk determined based on age, sex, HIV status, and transfer status. Apparent overlap of ranges in baseline risk between adjacent quartiles of baseline risk is due to rounding.



eTable 5. Incremental Discrimination of qSOFA Score or SIRS Criteria Added to Baseline Risk Model For Hospital Mortality Among Patients With Suspected Infection in the Individual and Combined Cohorts

Cohort

AUROC [95% CI],

Baseline Risk

AUROC [95% CI],

Baseline Risk + qSOFA Score

AUROC [95% CI],

Baseline Risk + SIRS Criteria

∆ AUROC, +qSOFA

Score P-value

∆ AUROC, +SIRS

Criteria P-value

∆ AUROC, +qSOFA

Score vs +SIRS Criteria P-value

Individual Cohorts Kigali1 0.62 [0.54-0.70] 0.63 [0.55-0.71] 0.63 [0.55-0.70] 0.01 0.58 0.01 0.71 0.003 0.82 Gitwe 0.80 [0.74-0.86] 0.82 [0.76-0.88] 0.84 [0.78-0.89] 0.02 0.25 0.03 0.14 -0.01 0.45 Suspected

Lassa2 0.59 [0.51-0.67] 0.64 [0.56-0.71] 0.67 [0.60-0.75]

0.05 0.14 0.08 0.03 -0.04 0.26

Haiti-RELIC 13 0.68 [0.56-0.79] 0.85 [0.76-0.93] 0.79 [0.71-0.87] 0.17 <0.001 0.11 0.02 0.06 0.14 Haiti-RELIC 24 0.87 [0.76-0.99] 0.92 [0.84-0.99] 0.87 [0.75-0.99] 0.04 0.20 -0.002 0.80 0.05 0.20 Ubon-Sepsis6 0.63 [0.58-0.68] 0.70 [0.65-0.75] 0.63 [0.58-0.69] 0.07 0.01 0.004 0.62 0.06 0.009 SEAQUAMAT8 0.58 [0.54-0.62] 0.65 [0.61-0.69] 0.59 [0.55-0.63] 0.07 0.001 0.01 0.28 0.06 0.001 Vietnam9 0.65 [0.60-0.71] 0.72 [0.67-0.78] 0.66 [0.61-0.72] 0.07 0.02 0.01 0.47 0.06 0.02 Sri Lanka10 0.80 [0.71-0.90] 0.85 [0.75-0.94] 0.84 [0.76-0.93] 0.04 0.15 0.04 0.04 0.01 0.79 Combined Cohorts 0.56 [0.53-0.58] 0.70 [0.68-0.72] 0.59 [0.57-0.62] 0.15 <0.001 0.04 <0.001 0.11 <0.001 Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome; AUROC, area under the receiver operating characteristic curve. Baseline risk determined based on age, sex, HIV status, and transfer status. The AUROC data derive from the baseline model alone, baseline model plus qSOFA score (range, 0-3), and baseline model plus SIRS criteria (range, 0-4). P-values <0.02 considered significant due to multiple testing adjustment.



eTable 6. Incremental Discrimination of qSOFA Score or SIRS Criteria Added to Baseline Risk Model For Hospital Mortality Among Patients With Suspected Infection in the Individual and Combined Cohorts, by HIV Status and Infection Type

Infection Type

AUROC [95% CI],

Baseline Risk

AUROC [95% CI],

Baseline Risk + qSOFA Score

AUROC [95% CI],

Baseline Risk + SIRS Criteria

∆ AUROC, +qSOFA

Score P-value

∆ AUROC, +SIRS

Criteria P-value

∆ AUROC, +qSOFA

Score vs +SIRS Criteria P-value

HIV Kigali1 0.58 [0.47-0.69] 0.64 [0.53-0.75] 0.60 [0.49-0.72] 0.06 0.17 0.03 0.47 0.03 0.37 Vietnam9 0.53 [0.23-0.83] 0.71 [0.44-0.97] 0.59 [0.28-0.90] 0.17 0.10 0.06 0.48 0.12 0.10 Combined Cohorts 0.57 [0.49-0.66] 0.66 [0.57-0.75] 0.57 [0.49-0.66] 0.11 0.08 0.00 0.96 0.09 0.03 Malaria Gitwe 0.85 [0.79-0.92] 0.87 [0.78-0.97] 0.89 [0.82-0.96] 0.02 0.51 0.04 0.29 -0.02 0.66 SEAQUAMAT8 0.58 [0.54-0.63] 0.65 [0.61-0.69] 0.59 [0.54-0.63] 0.07 0.001 0.005 0.34 0.07 0.001 Combined Cohorts 0.59 [0.55-0.76] 0.71 [0.68-0.75] 0.58 [0.54-0.62] 0.12 <0.001 -0.01 0.26 0.13 <0.001 Dengue Vietnam9 0.66 [0.56-0.76] 0.76 [0.67-0.85] 0.68 [0.58-0.77] 0.10 0.04 0.02 0.47 0.08 0.07 Combined Cohorts 0.73 [0.63-0.82] 0.78 [0.69-0.87] 0.71 [0.62-0.81] 0.05 0.22 -0.01 0.42 0.07 0.10 Pneumonia Kigali1 0.69 [0.49-0.89] 0.71 [0.52-0.90] 0.72 [0.52-0.92] 0.02 0.65 0.03 0.41 -0.01 0.82 Haiti-RELIC 13 0.65 [0.29-1.00] 0.82 [0.57-1.00] 0.64 [0.27-1.00] 0.17 0.40 -0.01 0.96 0.18 0.12 Ubon-Sepsis6 0.57 [0.47-0.67] 0.61 [0.52-0.70] 0.55 [0.45-0.64] 0.04 0.46 -0.02 0.46 0.07 0.17 Vietnam9 0.63 [0.52-0.75] 0.76 [0.67-0.86] 0.63 [0.51-0.75] 0.13 0.04 -0.005 0.71 0.13 0.03 Sri Lanka10 0.81 [0.66-0.97] 0.82 [0.66-0.97] 0.85 [0.71-0.98] 0.01 0.49 0.03 0.29 -0.03 0.36 Combined Cohorts 0.59 [0.53-0.64] 0.66 [0.61-0.72] 0.58 [0.52-0.64] 0.08 0.01 -0.005 0.73 0.08 0.001 Tuberculosis Kigali1 0.61 [0.45-0.75] 0.60 [0.45-0.75] 0.60 [0.45-0.75] -0.003 0.90 0.002 0.96 -0.004 0.89 Combined Cohorts 0.63 [0.52-0.74] 0.63 [0.52-0.74] 0.63 [0.52-0.74] 0.003 0.93 0.009 0.66 -0.006 0.81 Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome; AUROC, area under the receiver operating characteristic curve. Baseline risk determined based on age, sex, HIV status, and transfer status. Infection type was preferentially classified according to lab-confirmed diagnosis. When this was unavailable or inapplicable, patients were classified according to discharge diagnosis or, lastly, according to admission diagnosis. Separate models were created for each cohort or infection subgroup with sufficient data for models to converge; the variables in each model remained the same but the coefficients were specific to each cohort or infection subgroup. The entire combined cohort was stratified according to HIV status and type of infection, such that all patients with the specified type of infection are included in the analysis, regardless of cohort. For example, the combined cohort of tuberculosis patients includes patients from seven of the nine cohorts. The AUROC data derive from the baseline



model alone, baseline model plus qSOFA score (range, 0-3), and baseline model plus SIRS criteria (range, 0-4). P-values <0.017 considered significant due to Bonferroni multiple testing adjustment.

eTable 7. Predictive Validity of qSOFA Score and SIRS Criteria in the Combined Cohort, Sensitivity Analyses

Method

Number of

Cohorts Included

in Analysis

Number of Patients Included

in Analysis,

(%)

OR for Hospital Mortality

with qSOFA score ≥2 vs <2 [95% CI],

P-value

OR for Hospital Mortality with SIRS criteria ≥2 vs <2 [95% CI], P-value

AUROC [95% CI], Baseline

Risk


Risk + qSOFA

Score


Risk + SIRS Criteria

Original methods 9 6569 (100) 3.6 [3.0-4.2],

P<0.001 1.7 [1.4-2.0],

P<0.001 0.56 [0.53-

0.58] 0.70 [0.68-

0.72] 0.59 [0.57-

0.62] Sensitivity analysis 1: excluded cohorts that specified enrolment based on SIRS criteria 7 5254 (80)

4.2 [3.5-5.1], P<0.001

2.2 [1.8-2.7], P<0.001

0.56 [0.53-0.59]

0.73 [0.71-0.75]

0.64 [0.61-0.66]

Sensitivity analysis 2: excluded cohorts systematically missing components of qSOFA score or SIRS criteria 7 3498 (53)

2.2 [1.8-2.7], P<0.001

1.3 [1.1-1.7], P=0.01

0.56 [0.53-0.59]

0.64 [0.61-0.66]

0.56 [0.54-0.59]

Sensitivity analysis 3: excluded patients below age 18 years 9 6493 (99)

3.6 [3.0-4.3], P<0.001

1.7 [1.4-2.0], P<0.001

0.56 [0.53-0.58]

0.71 [0.69-0.73]

0.59 [0.57-0.62]

Sensitivity analysis 4: complete case analysis 5 1496 (23)

2.1 [1.4-3.1], P<0.001

1.2 [0.8-2.1], P=0.36

0.59 [0.54-0.63]

0.65 [0.60-0.69]

0.57 [0.52-0.62]

Sensitivity analysis 5: excluded cohorts that reported worst of multiple observations of SIRS and qSOFA component variables in first 24 hours 6 2875 (44)

2.3 [1.8-2.8], P<0.001

1.4 [1.1-1.7], P=0.002

0.55 [0.52-0.58]

0.64 [0.62-0.67]

0.58 [0.56-0.61]

Sensitivity analysis 6: excluded cohorts that did not record patient transfer status 5 2397 (36)

1.9 [1.5-2.5], P<0.001

1.0 [0.78-1.4], P=0.75

0.62 [0.58-0.65]

0.67 [0.63-0.70]

0.60 [0.57-0.63]

Sensitivity analysis 7: excluded cohorts that did not record patient HIV status 6 2958 (45)

2.1 [1.7-2.7], P<0.001

1.3 [1.0-1.7], P=0.05

0.65 [0.62-0.68]

0.69 [0.66-0.72]

0.64 [0.61-0.67]

Sensitivity analysis 8: MICE

9

6569 (100)

2.6 [2.1-2.9],

P<0.001a

2.3 [2.3-2.3],

P<0.001a 0.79 [0.79-

0.79] 0.82 [0.82-

0.82] 0.80 [0.80-

0.80]



Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome; HIV, human immunodeficiency virus; MICE, multiple imputation using chained regression equations. a Data in brackets represent range across 5 imputation cycles, rather than 95% CI



eTable 8. Mortality Prediction of qSOFA Score and SIRS Criteria in the Individual and Combined Cohorts

Cohort AUROC [95% CI], qSOFA Score AUROC [95% CI], SIRS Criteria

Individual Cohorts

Kigali1 0.55 [0.48-0.63] 0.55 [0.47-0.62]

Gitwe 0.64 [0.55-0.74] 0.66 [0.57-0.76]

Suspected Lassa2 0.59 [0.52-0.66] 0.64 [0.57-0.71]

Haiti-RELIC 13 0.81 [0.73-0.89] 0.73 [0.64-0.82]

Haiti-RELIC 24 0.72 [0.58-0.86] 0.62 [0.47-0.77]

Ubon-Sepsis6 0.64 [0.58-0.69] 0.52 [0.46-0.58]

SEAQUAMAT8 0.62 [0.59-0.66] 0.51 [0.47-0.55]

Vietnam9 0.68 [0.62-0.73] 0.59 [0.53-0.65]

Sri Lanka10 0.72 [0.61-0.83] 0.65 [0.55-0.75]

Combined Cohorts 0.69 [0.67-0.71] 0.59 [0.57-0.61] Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome.



eFigure 1. Distribution of Patients by qSOFA Score and SIRS Criteria Among Patients With Suspected Infection in the Individual Cohorts

0 1 2 30

20

40

60

qSOFA Score

Enc

ount

ers,

%

No. of patients per score112 128 55 7

(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Enc

ount

ers,

%


(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Enc

ount

ers,

%


(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Enc

ount

ers,

%

No. of patients per criterion

69 95 82 47 9

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Enc

ount

ers,

%


124 159 163 97 18

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Enc

ount

ers,

%


64 166 199 103 8

(Best) (Worst)

A. Kigali (N=302)1

B. Gitwe (N=561)

C. Suspected Lassa (N=540)2



eFigure 1 Continued.

0 1 2 30

10

20

30

40

50

qSOFA Score

Enc

ount

ers,

%


(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Enc

ount

ers,

%

50% [40-59%]


(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Enc

ount

ers,

%


(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Enc

ount

ers,

%


46 25 44 38 3

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Enc

ount

ers,

%42% [33-52%]49% [39-58%]


0 1 51 44 9

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Enc

ount

ers,

%


19 96 289 529 277

(Best) (Worst)

D. Haiti-RELIC1 (N=156)3

E. Haiti-RELIC2 (N=105)4

F. Ubon-Sepsis (N=1,210)6




Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome. Maximum qSOFA score and SIRS criteria were calculated based on all available information in the first 24 hours after presentation to study hospital. Where columns or error bars are truncated, the percentage of encounters and 95% CI are noted above the figure. Error bars indicate 95% confidence intervals.

0 1 2 30

10

20

30

40

50

qSOFA Score

Enc

ount

ers,

%


(Best) (Worst)

0 1 2 30

20

40

60

qSOFA Score

Enc

ount

ers,

%


(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Enc

ount

ers,

%


(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Enc

ount

ers,

%

50% [47-52%]


190 569 389 0 0

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Enc

ount

ers,

%


154 149 158 124 39

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Enc

ount

ers,

%


810 726 312 75 0

(Best) (Worst)

G. SEAQUAMAT (N=1,148)8

H. Vietnam (N=624)9

I. Sri Lanka (N=1,923)10



eFigure 2. Observed Mortality by qSOFA Score and SIRS Criteria Among Patients With Suspected Infection in the Individual Cohorts

0 1 2 30

10

20

30

40

50

qSOFA Score

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

112 128 55 7

No. of patients per score

43% [13-79%]

(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

238 214 93 13


23% [7.2-54%]

(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

33 79 101 3


33% [2.5-91%]47% [37-56%]

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

No. of patients per criteria

69 95 82 47 9

33% [10-69%]

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)


123 158 163 96 18

28% [12-53%]

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)


21 49 89 53 4

100%60% [47-73%]29% [13-51%]

(Best) (Worst)

A. Kigali (N=302)1

B. Gitwe (N=558)

C. Suspected Lassa (N=216)2




0 1 2 30

10

20

30

40

50

qSOFA Score

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

41 59 39 8


100%

(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

9 41 51 3


67% [9.3-98%]

(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

181 437 536 56


(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)


38 25 44 37 3

100%

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)


0 1 51 43 9

11% [1.3-54%]

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)


19 96 289 529 277

(Best) (Worst)

D. Haiti-RELIC1 (N=147)3

E. Haiti-RELIC2 (N=104)4

F. Ubon-Sepsis (N=1,210)6




Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome. Maximum qSOFA score and SIRS criteria were calculated based on all available information in the first 24 hours after presentation to study hospital. Where columns or error bars are truncated, the percentage of encounters and 95% CI are noted above the figure. Error bars indicate 95% confidence intervals. Only those patients with known outcome status were included in the analytic sample.

0 1 2 30

10

20

30

40

50

qSOFA Score

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

85 314 496 239


(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

130 294 183 17


41% [21-65%]

(Best) (Worst)

0 1 2 30

10

20

30

40

50

qSOFA Score

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)

834 835 228 26


(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)


187 562 385 0 0

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)


154 149 158 124 39

(Best) (Worst)

0 1 2 3 40

10

20

30

40

50

SIRS Criteria

Pro

port

ion

with

Hos

pita

l Mor

talit

y (%

)


810 726 312 75 0

(Best) (Worst)

G. SEAQUAMAT (N=1,134)8

H. Vietnam (N=624)9

I. Sri Lanka (N=1,923)10



eFigure 3. Risk Ratio for Hospital Mortality (Log-Scale) Comparing Encounters With Moderate (1) and High (2) vs Low (0) qSOFA Score and SIRS Criteria Among Patients With Suspected Infection by Individual Cohort (A) and Odds Ratio for Hospital Mortality (Log-Scale) Comparing Encounters with Moderate (1) and High (2) vs Low (0) qSOFA Score and SIRS Criteria Among Patients With Suspected Infection by Quartile of Baseline Risk for Hospital Mortality in the Combined Cohort (B)

Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome. Baseline risk determined based on age, sex, HIV status, and transfer status. No patients with 0 qSOFA points died in the Haiti-RELIC1 cohort, and no patients with 0 SIRS criteria died in the Haiti-RELIC1 and Haiti-RELIC2 cohorts; therefore these cohorts are omitted from panel A. Error bars indicate 95% confidence intervals. Apparent overlap of ranges in baseline risk between adjacent quartiles of baseline risk is due to rounding.

0.1 1 10 100

Sri Lanka

Vietnam

SEAQUAMAT

Ubon-Sepsis

Suspected Lassa

Gitwe

Kigali

Risk Ratio for Hospital Mortality

Coh

ort

qSOFA 2 vs qSOFA 0

qSOFA 1 vs qSOFA 0

0.1 1 10 100

Quartile 1

Quartile 2

Quartile 3

Quartile 4

Odds Ratio for Hospital Mortality

Qua

rtile

of B

asel

ine

Ris

k of

Hos

pita

l Mor

talit

y(B

asel

ine

Ris

k M

ean

[Ran

ge])

qSOFA 2 vs qSOFA 0

qSOFA 1 vs qSOFA 0

(12% [10-13%])

(14% [13-16%])

(18% [16-20%])

(25% [20-47%])

0.1 1 10 100

Sri Lanka

Vietnam

SEAQUAMAT

Ubon-Sepsis

Suspected Lassa

Gitwe

Kigali

Risk Ratio for Hospital Mortality

Coh

ort

SIRS 2 vs SIRS 0

SIRS 1 vs SIRS 0

0.1 1 10 100

Quartile 1

Quartile 2

Quartile 3

Quartile 4


Qua

rtile

of B

asel

ine

Ris

k of

Hos

pita

l Mor

talit

y(B

asel

ine

Ris

k M

ean

[Ran

ge])

SIRS 2 vs SIRS 0

SIRS 1 vs SIRS 0

(12% [10-13%])

(14% [13-16%])

(18% [16-20%])

(25% [20-47%])

A. Individual Cohorts

B. Combined Cohort



eFigure 4. Receiver Operating Characteristic Curves for qSOFA Score or SIRS Criteria Added to Baseline Risk Model for Hospital Mortality Among Patients With Suspected Infection in the Individual Cohorts

A. Kigali B. Gitwe1

C. Suspected Lassa2

E. Haiti - RELIC24

D. Haiti - RELIC13

F. Ubon - Sepsis6




Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome; AUROC, area under the receiver operating characteristic curve. The AUROC data derive from the baseline model alone, baseline model plus qSOFA score (range, 0-3), and baseline model plus SIRS criteria (range, 0-4). Baseline risk determined based on age, sex, HIV status, and transfer status. Panel A, Kigali AUROCs: Baseline Risk Model, 0.62 (95% CI, 0.54-0.70); Baseline Risk Plus qSOFA, 0.63 (95% CI, 0.55-0.71); Baseline Risk Plus SIRS, 0.63 (95% CI, 0.55-0.70). Panel B, Gitwe AUROCs: Baseline Risk Model, 0.80 (95% CI, 0.74-0.86); Baseline Risk Plus qSOFA, 0.82 (95% CI, 0.76-0.88); Baseline Risk Plus SIRS, 0.84 (95% CI, 0.78-0.89). Panel C, Suspected Lassa AUROCs: Baseline Risk Model, 0.59 (95% CI, 0.51-0.67); Baseline Risk Plus qSOFA, 0.64 (95% CI, 0.56-0.71); Baseline Risk Plus SIRS, 0.67 (95% CI, 0.60-0.75). Panel D, Haiti-RELIC1 AUROCs: Baseline Risk Model, 0.68 (95% CI, 0.56-0.79); Baseline Risk Plus qSOFA, 0.85 (95% CI, 0.76-0.93); Baseline Risk Plus SIRS, 0.79 (95% CI, 0.71-0.87). Panel E, Haiti-RELIC2 AUROCs: Baseline Risk Model, 0.87 (95% CI, 0.76-0.99); Baseline Risk Plus qSOFA, 0.92 (95% CI, 0.84-0.99); Baseline Risk Plus SIRS, 0.87 (95% CI, 0.75-0.99). Panel F, Ubon-Sepsis AUROCs: Baseline Risk Model, 0.63 (95% CI, 0.58-0.68); Baseline Risk Plus qSOFA, 0.70 (95% CI, 0.65-0.75); Baseline Risk Plus SIRS, 0.63 (95% CI, 0.58-0.69). Panel G, SEAQUAMAT AUROCs: Baseline Risk Model, 0.58 (95% CI, 0.54-0.62); Baseline Risk Plus qSOFA, 0.65 (95% CI, 0.61-0.69); Baseline Risk Plus SIRS, 0.59 (95% CI, 0.55-0.63). Panel H, Vietnam AUROCs: Baseline Risk Model, 0.65 (95% CI, 0.60-0.71); Baseline Risk Plus qSOFA, 0.72 (95% CI, 0.67-0.78); Baseline Risk Plus SIRS, 0.66 (95% CI, 0.61-0.72). Panel I, Sri Lanka AUROCs: Baseline Risk Model, 0.80 (95% CI, 0.71-0.90); Baseline Risk Plus qSOFA, 0.85 (95% CI, 0.75-0.94); Baseline Risk Plus SIRS, 0.84 (95% CI, 0.76-0.93).

I. Sri Lanka10

G. SEAQUAMAT8 H. Vietnam9



eFigure 5. Odds Ratio for Hospital Mortality (Log-Scale) Comparing Encounters With 2 vs <2 qSOFA Points and 2 vs <2 SIRS Criteria Among Patients With Suspected Infection, by HIV Status and Infection Type

Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome. Baseline risk determined based on age, sex, HIV status, and transfer status. Infection type was preferentially classified according to lab-confirmed diagnosis. When this was unavailable or inapplicable, patients were classified according to discharge diagnosis or, lastly, according to admission diagnosis. For subgroup analyses within the combined cohort, the entire combined cohort was stratified according to HIV status and infection type, such that all patients with the specified infection type are included in the analysis, regardless of cohort. For example, the combined cohort of tuberculosis patients includes patients from seven of the nine cohorts. Error bars indicate 95% confidence intervals.

0.1 1 10 100

Combined

Vietnam

Kigali


Coh

ort

0.1 1 10 100

Combined

Vietnam


Coh

ort

0.1 1 10 100

Combined

Kigali


Coh

ort

0.1 1 10 100

Combined

SEAQUAMAT

Gitwe


Coh

ort

0.1 1 10 100

Combined

Sri Lanka

Vietnam

Ubon-Sepsis

Haiti-RELIC 1

Kigali


Coh

ort

A. HIV Positive B. Malaria

C. Dengue D. Pneumonia

E. Tuberculosis

Legend



eFigure 6. Discrimination of qSOFA Score or SIRS Criteria Added to Baseline Risk Model for Hospital Mortality Among Patients With Suspected Infection, by HIV Status and Infection Type

Abbreviations: qSOFA, quick Sequential [Sepsis-related] Organ Failure Assessment; SIRS, systemic inflammatory response syndrome; AUROC, area under the receiver operating characteristic curve. The AUROC data derive from the baseline model alone, baseline model plus qSOFA score (range, 0-3), and baseline model plus SIRS criteria (range, 0-4). Baseline risk determined based on age, sex, HIV status, and transfer status. Infection type was preferentially classified according to lab-confirmed diagnosis. When this was unavailable or inapplicable, patients were classified according to discharge diagnosis or, lastly, according to admission diagnosis. Separate models were created for each cohort or infection subgroup with sufficient data for models to converge; the variables in each model remained the same but the coefficients were specific to each cohort or infection subgroup. For subgroup analyses within the combined cohort, the entire combined cohort was stratified according to HIV status and infection type, such that

0.2 0.4 0.6 0.8 1.0

Combined

Vietnam

Kigali

Area Under Receiver Operating Characteristic Curve

Coh

ort

0.2 0.4 0.6 0.8 1.0

Combined

Vietnam


Coh

ort

0.2 0.4 0.6 0.8 1.0

Combined

Kigali


Coh

ort

0.2 0.4 0.6 0.8 1.0

Combined

SEAQUAMAT

Gitwe


Coh

ort

0.2 0.4 0.6 0.8 1.0

Combined

Sri Lanka

Vietnam

Ubon-Sepsis

Haiti-RELIC 1

Kigali


Coh

ort

A. HIV Positive B. Malaria

C. Dengue D. Pneumonia

E. Tuberculosis

Legend



all patients with the specified infection type are included in the analysis, regardless of cohort. Error bars indicate 95% confidence intervals.



eReferences 1. Aluisio AR, Garbern S, Wiskel T, et al. Mortality outcomes based on ED qSOFA

score and HIV status in a developing low income country. Am J Emerg Med. 2018:(Epub ahead of print). doi:10.1016/j.ajem.2018.03.014.

2. Shaffer JG, Grant DS, Schieffelin JS, et al. Lassa Fever in Post-Conflict Sierra Leone. PLoS Negl Trop Dis. 2014;8(3). doi:10.1371/journal.pntd.0002748.

3. Papali A, Verceles AC, Augustin ME, et al. Sepsis in Haiti: Prevalence, Treatment, and Outcomes in a Port-au-Prince Referral Hospital. J Crit Care. 2017;38:35-40. doi:10.1016/j.jcrc.2016.09.031.

4. Papali A, West TE, Verceles AC, et al. Treatment outcomes after implementation of an adapted WHO protocol for severe sepsis and septic shock in Haiti. J Crit Care. 2017;41:222-228. doi:10.1016/j.jcrc.2017.05.024.

5. Jacob ST, Lim M, Banura P, et al. Integrating sepsis management recommendations into clinical care guidelines for district hospitals in resource-limited settings: the necessity to augment new guidelines with future research. BMC Med. 2013;11:107. doi:10.1186/1741-7015-11-107.

6. Teparrukkul P, Hantrakun V, Day NPJ, West TE, Limmathurotsakul D. Management and outcomes of severe dengue patients presenting with sepsis in a tropical country. PLoS One. 2017;12(4):1-13. doi:10.1371/journal.pone.0176233.

7. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637. doi:10.1097/CCM.0b013e31827e83af.

8. SEAQUAMAT Group. Artesunate versus quinine for treatment of severe falciparum malaria: A randomised trial. Lancet. 2005;366(9487):717-725. doi:10.1016/S0140-6736(05)67176-0.

9. Thuy DB, Campbell J, Hoang NVM, et al. A one-year prospective study of colonization with antimicrobial-resistant organisms on admission to a Vietnamese intensive care unit. PLoS One. 2017;12(9):e0184847.

10. Beane A, De Silva AP, De Silva N, et al. Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in low-middle income country setting. BMJ Open. 2018;8(e019387). doi:10.1136/bmjopen-2017-019387.


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