The role of sepsis screening, SIRS and qSOFA in head and neck infections: An audit of 104 patients

Sepsis is associated with high morbidity and mortality and is a known complication of infections of the head and neck. Screening for sepsis should be conducted on admission in order to identify patients at risk and provide early intervention. Compliance with sepsis screening was poor on an ENT ward in a district general hospital, however this can be improved further by education and visual reminders such as poster or a clerking proforma. The most common head and neck infections admitted to a district general hospital were tonsillitis, peritonsillar cellulitis and peritonsillar abscesses. The incidence of sepsis as a complication of head and neck infections is very rare if using the qSOFA criteria. Using SIRS criteria may result in overidentification of sepsis and may lead to excessive and inappropriate clinical management in patients who could otherwise be managed less aggressively.


| BACKG ROU N D
The rate of admissions with infections of the head and neck is rising. 1 Whilst the nature of complications can vary hugely depending on the primary source of infection, they all carry significant morbidity and mortality if not treated early. 2 One such complication is sepsis, defined as 'a life-threatening organ dysfunction caused by a dysregulated host response to infection'. 3 It is associated with mortality rates up to 8.6%. 4 In 2016, a task force re-examined the definitions and criteria of sepsis and the result was the Third International Consensus Definition 3 where it was proposed that sepsis is a result of dysregulation to normal physiology rather than an inflammatory condition. As a result, instead of using Systemic Inflammatory Response Syndrome (SIRS) Criteria 3 to diagnose sepsis, the Sequential Organ Dysfunction Score (SOFA) was proposed as the most suitable modality in diagnosing sepsis (Table 1).
However, for frontline clinicians, the SOFA score was not useful as a quick bedside screening tool to identify sepsis due to the inclusion of laboratory markers which may take time. Thus, the taskforce proposed quick SOFA (qSOFA) that only includes 3 easily obtainable bedside parameters ( Figure 1) for quick identification of sepsis. 5 In the context of ENT/OMFS, the available literature was generally limited to reporting sepsis as one of many life-threatening sequalae, 6 but exact figures on incidence, prevalence, mortality and disease burden remain undetermined. Thus, we set out to conduct an audit to investigate sepsis among HNIs in an acute otolaryngology setting with the following aims: -To determine the compliance with sepsis screening among inpatient admissions with head and neck infections in a district general hospital -To assess the demographics of inpatient admissions and nature of infections -To compare differences in rate of diagnosing sepsis when using

SIRS criteria versus qSOFA criteria
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| Ethical considerations
The study was undertaken as an audit with approval from the Doncaster Royal Infirmary Department of Audit and Clinical Governance.

| RE SULTS
A total of 104 patients were admitted with HNI over the 2 audit cycles.
None of the patients underwent sepsis screening; however, no patients met the qSOFA criteria for sepsis either when screened retrospectively.
In the second cycle, there were 60 admissions with HNIs with a mean length of stay of 2 days (range 0-13 days). The most common diagnosis was again tonsillitis (n = 18, 30%) followed by peritonsillar abscess/quinsy (n = 13, 21.6%). Following the interventions, sepsis screening rate improved to 46% (n = 28). One patient met the qSOFA criteria for sepsis and this was picked up on screening; however, 29 patients (48.3%) were septic according to the SIRS criteria.
The patient who had met the criteria for sepsis had a diagnosis of supraglottitis with neck cellulitis. Whist the patient was treated with intravenous fluids and antibiotics, there was no evidence of the 'sepsis six' being undertaken. Post-tonsillectomy bleeds were included as HNIs, as these patients presented more than 24 hours post-op with raised inflammatory markers and other features suggesting bleeds secondary to infection (Table 2, Figure 2).

Key points
• Sepsis is associated with high morbidity and mortality and is a known complication of infections of the head and neck. Screening for sepsis should be conducted on admission in order to identify patients at risk and provide early intervention.
• Compliance with sepsis screening was poor on an ENT ward in a district general hospital; however, this can be improved further by education and visual reminders such as poster or a clerking proforma.
• The most common head and neck infections admitted to a district general hospital were tonsillitis, peritonsillar cellulitis and peritonsillar abscesses.
• The incidence of sepsis as a complication of head and neck infections is very rare if using the qSOFA criteria.  We also found that tonsillitis, peritonsillar cellulitis and peritonsillar abscesses form a significant proportion of inpatient admissions (60% or more); however, the rate of sepsis is quite low. In fact, only 1 out of 104 patients was septic if using the qSOFA criteria.

| Strengths of the study
There is currently limited literature on the outcomes, morbidity and mortality specific to head and infections. To our knowledge, our study is the first one comparing the clinical applicability of qSOFA versus SIRS in HNIs. We have also shown that though serious and a definite complication to look out for, sepsis is a rare occurrence among this cohort of patients. Tonsillitis and peritonsillar abscesses still represent a significant proportion of admissions among district general hospital and these are usually younger patients with less co-morbidities.
We also highlighted that despite 'sepsis' being a topic of sig-

| Comparison with other studies
There has been widespread debate about the sensitivity and specificity of SIRS and qSOFA in recognising sepsis since the new criteria have been introduced. qSOFA was thought to be more specific while SIRS was more sensitive. 7 It has also been reported that SIRS was more accurate in predicting an established infection. 8,9 Comparison with National Early Warning Score (NEWS/NEWS2) has also been reported with the study demonstrating that NEWS was equally good in predicting unwell patients compared to either SIRS or qSOFA and may be more relevant as it is already widely adopted among UK hospitals. 10 These studies were often conducted in an emergency department or acute medical setting; however, there is no literature currently specific to HNIs.

| Clinical applicability of the study
The standard response to sepsis would be implementation of Sepsis

| CON CLUS ION
Head and neck infections are common and form a significant proportion of inpatients in ENT wards. Although sepsis as a complication is relatively rare, sepsis screening is a first step in recognizing vulnerable patients and this should be clearly documented. Compliance with sepsis screening can be improved with education and visual reminders such as posters or clerking proformas. qSOFA is more clinically appropriate as a screening tool in this population, as SIRS can result in falsely high rates of sepsis and hence potentially unnecessary treatments for patients.

CO N FLI C T O F I NTE R E S T
None held.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request.