Comparison of the qSOFA and CRB 65 for risk prediction in patients with community acquired pneumonia
Dear Editors, Community acquired pneumonia (CAP) is a major source of sepsis, and sepsis related acute organ dysfunction determines patient outcome. Therefore, early risk stratification using clinical scores such as the CRB( 65) and subsequent evaluation for organ dysfunction to identify high risk patients should be the standard of care [1] For sepsis, new criteria (Sepsis 3) have recently been proposed including a qSOFA score as a rapid screening tool [2] The qSOFA was validated within various datasets of heterogeneous sepsis patients [3] and consists of the same three clinical parameters used in CRB but with different cut offs for tachypnea (respiratory rate =22/min vs. =30/min in CRB) and hypotension (systolic blood pressure =100 mmHg vs. <90 mmHgsys or =60 mmHgdias) [2, 4] A cut off of =2 qSOFA criteria provided mortality prediction as good as the more complex SOFA score in non ICU patients. However, the original datasets used to establish qSOFA were not stratified according to the primary source of sepsis. In this study, we performed a multicenter validation of the qSOFA in patients with CAP and compared accuracy to predict disease course to the CRB( 65) score. Patient data were collected from the multicenter German CAPNETZ database. All patients entering the database between October 2002 and June 2015 with complete data on the underlying CRB 65/qSOFA quantitative measurements and the predefined outcomes 30 day mortality, need of mechanical ventilation (MV) or vasopressor support (VS) were considered eligible. Patients already being mechanically ventilated at hospital admission were excluded (273/9600, 2.8 A detailed description of the methodology is given in the supplementary material. Baseline characteristics of the 9327 evaluated patients are given in Table S1. We found that, for each score point of CRB and qSOFA, mortality rates increased. Overall accuracy of the qSOFA score did not differ from CRB score for prediction of 30 day mortality or requirement for MV/VS (p 0.05, Table 1; Fig. S1) At the cut off of 2 points, sensitivity was higher while specificity was lower for qSOFA as compared to CRB (Table S2) Positive predictive values were low for both scores. For low risk prediction, both scores showed inadequate sensitivity, but a qSOFA of 0 might be preferable to the CRB of 0 for the prediction of the combined outcome (sensitivity 74 vs. 58 Low risk prediction by both scores was improved after including the age criterion =65 years (p 0.001) with a qSOFA 65 0 missing only 26 patients with the combined outcome mortality/MV/VS (NPV 99.1 Sensitivity for the combined outcome was 94 (qSOFA65 0) versus 89 (CRB 65 0) respectively (Table S2) If we compare our results to those in the available literature, our AUCs of the qSOFA for mortality prediction are comparable to those of the original report [3] and another validation study [5] including patients at risk of sepsis outside the ICU (AUC 0.79 corrected for "baseline *Correspondence: martin.kolditz@uniklinikum dresden.de 1 Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Fetscherstr. 74, 01307 Dresden, Germany Full author information is available at the end of the article The members of the CAPNETZ study group (except the authors) are listed in the Acknowledgments.
Intensive Care Medicine