What is the recommended clinical scoring system for sepsis?

Recommended Clinical Scoring Systems for Sepsis

The Sequential Organ Failure Assessment (SOFA) score is the recommended primary clinical scoring system for sepsis, with quick SOFA (qSOFA) serving as an initial rapid screening tool outside the ICU setting, and Sepsis-Induced Coagulopathy (SIC) scoring recommended for early detection of coagulation disorders in sepsis. 1, 2, 3

Primary Scoring System: SOFA

• SOFA evaluates dysfunction across six organ systems (respiratory, cardiovascular, neurological, renal, hepatic, and coagulation), with scores ranging from 0-4 for each system and a total score ranging from 0-24 2, 4
• According to Sepsis-3 definitions, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, represented by an increase in SOFA score of ≥2 points 1
• SOFA allows for sequential monitoring of patients throughout their ICU stay, enabling clinicians to track disease progression and response to treatment 2, 4
• The SOFA score has demonstrated good predictive ability for mortality with an area under the ROC curve of approximately 0.75 4

Rapid Screening Tool: qSOFA

• qSOFA consists of three clinical variables: Glasgow Coma Scale score ≤13, systolic blood pressure ≤100 mm Hg, and respiratory rate ≥22/min 3, 1
• qSOFA was designed for rapid bedside assessment outside the ICU to identify patients at risk of poor outcomes from sepsis 1, 5
• Patients with suspected infection and qSOFA score ≥2 have a 3-14 fold increased risk of hospital mortality across baseline risk deciles 6
• qSOFA has better specificity but lower sensitivity compared to SIRS criteria, making it more useful as a prognostic tool than a diagnostic tool 5, 7
• Among non-ICU encounters with suspected infection, qSOFA has demonstrated superior predictive validity for in-hospital mortality (AUROC = 0.81) compared to SOFA (AUROC = 0.79) and SIRS (AUROC = 0.76) 6

Coagulation Assessment: SIC Scoring System

• The Sepsis-Induced Coagulopathy (SIC) scoring system is recommended by the International Society on Thrombosis and Haemostasis (ISTH) for early detection of coagulation disorders in sepsis 3
• SIC is a simple and easy-to-use criterion for compensated DIC, suitable for prompt diagnosis and screening 3
• The SIC scoring system consists of readily available laboratory tests and incorporates the SOFA score, making it cost-effective and practical for repeated evaluation 3
• A two-step approach using SIC for screening followed by overt DIC criteria for definitive diagnosis is recommended as a pragmatic diagnostic tool 3

Comparative Performance of Scoring Systems

• In ICU settings, SOFA has better predictive validity for mortality (AUROC = 0.74) compared to qSOFA (AUROC = 0.66) and SIRS (AUROC = 0.64) 6
• Outside the ICU, qSOFA has better predictive validity (AUROC = 0.81) than SOFA (AUROC = 0.79) and SIRS (AUROC = 0.76) 6
• The National Early Warning Score (NEWS) has shown higher discrimination for in-hospital mortality (AUC = 0.77) compared to Modified Early Warning Score (MEWS) (AUC = 0.73), qSOFA (AUC = 0.69), and SIRS (AUC = 0.65) 7

Clinical Application and Pitfalls

• For patients with suspected sepsis in the ED, qSOFA can be used as an initial screening tool, with positive scores (≥2) indicating higher odds of mortality (OR: 3.9 at 7 days, OR: 6.9 at 28 days) 8
• SOFA should be calculated for all patients with suspected sepsis, particularly in ICU settings, to assess organ dysfunction and guide management 2, 1
• The SIC scoring system should be used to screen for coagulation disorders in sepsis patients, as mortality of SIC is high (approximately 30%) and that of overt DIC reaches approximately 40% 3
• A limitation of the SIC scoring system is its low specificity and adaptivity, as it is designed specifically for infectious diseases and may not correctly evaluate coagulation disorders in patients with liver dysfunction 3

Practical Implementation

• For initial assessment outside the ICU, calculate qSOFA score to rapidly identify patients at risk of poor outcomes 1, 8
• For comprehensive assessment, particularly in ICU settings, calculate the full SOFA score to evaluate organ dysfunction across all six systems 2, 4
• For patients with sepsis, screen for coagulation disorders using the SIC scoring system, followed by overt DIC criteria if SIC is positive 3
• Repeat scoring at regular intervals to monitor disease progression and response to treatment 2, 4