In our March 2016 What's New in the Patient Safety World column “” we welcomed a new consensus definition for sepsis that did away with the SIRS criteria (Singer 2016). For many years we had been on our soapbox about the games played where the patient with pneumonia happily pushing his IV pole up and down the hallway who meets a couple SIRS criteria gets coded as "sepsis", which of course gets a significantly higher reimbursement than pneumonia. The coding games largely skewed the mortality statistics for both “pneumonia” and “sepsis”. So it was with great enthusiasm that we welcomed the new definition that excluded the SIRS criteria.
But the usefulness of this new definition still needed validation in clinical settings. That validation has now come from 2 studies in several settings. Both studies looked at the ability of the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score and the quick SOFA (qSOFA) to predict mortality (see our March 2016 What's New in the Patient Safety World column “” for details of the new definitions). One validation study was done retrospectively in the ICU setting, the other prospectively in the emergency department setting.
Freund and colleagues found that among patients presenting to the emergency department with suspected infection, the use of qSOFA resulted in greater prognostic accuracy for in-hospital mortality than did either SIRS or severe sepsis (Freund 2017). These findings provide support for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria as a predictive tool, at least in the emergency department setting. The qSOFA in that setting was as good as the full SOFA in predicting mortality. Those patients with a qSOFA score of 2 or more had an in-hospital mortality rate of 24% whereas those with qSOFA scores <2 had a 3% mortality. Moreover, the addition of serum lactate did not further enhance the predictive value.
The SOFA score also does well at predicting mortality in ICU patients with sepsis but the shorter qSOFA may not fare as well in ICU patients. Raith and colleagues found that among adults with suspected infection admitted to an ICU, an increase in SOFA score of 2 or more had greater prognostic accuracy for in-hospital mortality than SIRS criteria or the qSOFA score (Raith 2017). In that study another more complex tool, the Logistic Organ Dysfunction System, also predicted ICU patient mortality better than the qSOFA. These findings suggest that SIRS criteria and qSOFA have limited utility for predicting mortality in an ICU setting. Note, though, that the qSOFA fared as well or better than Logistic Organ Dysfunction System or the full SOFA in sepsis patients not in the ICU.
In the editorial accompanying these two studies, Lamontagne and colleagues (Lamontagne 2017) stress that early identification of sepsis is still key and that, until future rapid diagnostic tests for sepsis are developed, the qSOFA is a simple tool that appears to be useful.
The Surviving Sepsis Campaign promptly responded to the new definition(s) in March 2016, noting that the implementation of the new definitions and related coding changes would take time for hospitals but reiterating that the new definitions do not change the primary focus of early sepsis identification and initiation of timely treatment (response March 2016).
Howell and colleagues also recently provided a summary of the updated guidelines for managing sepsis (Howell 2017). The highlights include:
There were also recommendations regarding mechanical ventilation parameters for patients with sepsis-related ARDS and a general statement that hospitals and health systems should implement formal programs to improve sepsis care that include sepsis screening. The full updated guideline will be in the March 2017 issue of Critical Care Medicine and is now available online (Rhodes 2017).
Time is of the essence in management of sepsis. We still need to focus on early recognition, timely antibiotics and adequate fluid resuscitation to reduce morbidity and mortality from “sepsis”. It does appear that the new definitions are steps in the right direction and will help us better manage sepsis going forward.
Our other columns on sepsis:
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315(8): 801-810
Freund Y, Lemachatti N, Krastinova E, et al. for the . Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality among Patients with Suspected Infection Presenting to the Emergency Department.
Raith EP, Udy AA, Bailey M, et al. Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality among Adults with Suspected Infection Admitted to the Intensive Care Unit. JAMA 2017; 317(3): 290-300
Surviving Sepsis Campaign website.
Surviving Sepsis Campaign. Surviving Sepsis Campaign Responds to Sepsis-3. March 1, 2016
Howell MD, Davis AM. Management of Sepsis and Septic Shock. JAMA 2017; Published online January 19, 2017.
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine 2017; 45(3): 1-67 Published-Ahead-of-Print Post Author Corrections: January 17, 2017