In reply:

Abstract

Mr. Gheen’s letter points out an important and common misconception in the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) about the difference between the new definitions and the clinical criteria for identifying sepsis.1Singer M. Deutschman C.S. Seymour C.W. et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016; 315: 801-810Crossref PubMed Scopus (11822) Google Scholar Specifically, many fail to notice that the task force defines sepsis as life-threatening organ dysfunction resulting from a dysregulated host response to infection while stating that an increase in Sequential Organ Failure Assessment (SOFA) or a quick Sequential Organ Failure Assessment (qSOFA) is a clinical criterion that should prompt appropriate investigations.1Singer M. Deutschman C.S. Seymour C.W. et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016; 315: 801-810Crossref PubMed Scopus (11822) Google Scholar (In my table’s title, the term definitions should have indeed been “clinical criteria.”) However, as Mr. Gheen rightly points out, in fact neither SOFA nor qSOFA can suffice as stand-alone definitions of sepsis. Nonetheless, without investing these tools with a modicum of diagnostic authority, under this new regime, it is no longer possible to diagnose sepsis until a presumably infected patient either dies or spends greater than or equal to 3 days in an ICU. This leaves a crucial question: under the new definitions, do emergency medicine providers retain “permission” to diagnose sepsis? Were we to conclude otherwise, emergency providers would be ceding diagnostic territory to inpatient teams who are no better at diagnosing or managing sepsis.2Powell E.S. Khare R.K. Courtney D.M. et al.Lower mortality in sepsis patients admitted through the ED vs direct admission.Am J Emerg Med. 2012; 30: 432-439Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar I would posit that we indeed still can diagnose sepsis, although perhaps with the proviso that we diagnose “sepsis until proven otherwise,” “presumed sepsis,” or, at a minimum, “high risk for sepsis.” This approach was tacitly endorsed by the task force’s vigorous assessment of the predictive validity of SOFA and qSOFA. In its prodigious data set, the task force found that in non-ICU patients (of whom half were in emergency departments; Seymour et al, Table 3), qSOFA in fact outperformed SOFA in predicting sepsis (81% more likely to have sepsis versus 79%; P<.001) and it far outperformed SIRS (81% more likely to have sepsis versus 76%; P<.001; Figure 3B).3Seymour C.W. Liu V.X. Iwashyna T.J. et al.Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016; 315: 762-774Crossref PubMed Scopus (2048) Google Scholar Therefore, for emergency medicine providers operationalizing the new definition, using either qSOFA or SOFA is statistically valid, although qSOFA appears to have the edge. Prospective validation is necessary and under way. So why did the task force not give qSOFA its full due? Without insider knowledge, we cannot know. However, we know that in circulated drafts of the consensus definitions some language gave qSOFA equal footing. However, the task force’s final published document is not immune from the scrutiny that all other peer-reviewed research receives. We are not obliged to read merely the conclusions and believe them blindly. That the authors underemphasized qSOFA’s performance in their tables is interesting but ultimately not compelling, as the data indicate. Many are confused by the relationship between qSOFA and SIRS. qSOFA does not replace SIRS, but it does, in my view, render it obsolete in many settings. This is likely good. SIRS fails to adequately distinguish normal host responses to infection from maladaptive ones; qSOFA apparently can. Algorithmically, though, qSOFA stands where SIRS once did, as anyone familiar with sepsis flowcharts will note. Removing SIRS was, as stated, an attempt to focus attention on identifying harmful dysregulated responses to infection and not appropriate responses. This is a welcome development. Sepsis-3 DefinitionsAnnals of Emergency MedicineVol. 68Issue 6PreviewI am concerned that the recent “No SIRS: Quick SOFA Instead” column authored by Jeremy Faust and featured in the May News & Perspectives section is inaccurate. Specifically, the table labeled Figure 1 and titled “Sepsis Definitions” in row 2, column 3 seems to have simply substituted quick Sequential Organ Failure Assessment (qSOFA) and Sequential Organ Failure Assessment (SOFA) in place of systemic inflammatory response syndrome (SIRS) in the old definition, implying that Sepsis-3 defines sepsis as “suspected or documented infection + ≥2 of qSOFA or Rise in SOFA score ≥2 points.” As presented in the table, this definition is not contained in the published findings of the Sepsis-3 investigators. Full-Text PDF