qSOFA should replace SIRS as the screening tool for sepsis

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Abstract

Vincent JL, Martin GS and Levy MM recently wrote an article in Critical Care entitled “qSOFA does not replace SIRS in the definition of sepsis” [1]. In this paper they specified that “the qSOFA is meant to be used to raise suspicion of sepsis and prompt further action but it is not a replacement for SIRS and is not part of the definition of sepsis”. One of the starting points that induced the Sepsis-3 consensus taskforce to set out in search of better entry criteria than the systemic inflammatory response syndrome (SIRS) criteria was precisely that SIRS criteria perform poorly on both “discriminant validity” and “convergent validity”[2]. In order to accomplish their task, they identified patients with suspected infection among 1.3 million health record cases and, after comparing the performance of several different clinical criteria, they came out with the quick sequential organ failure assessment (qSOFA) score, whose predictive validity for in-hospital mortality outside the ICU was statistically better than SIRS [3]. The fact that nonspecific SIRS criteria will “generally” continue to aid in the identification and diagnosis of infection was repeatedly affirmed in the Sepsis-3 consensus article [2]. Besides, when the SIRS criteria were first proposed as a screening tool for sepsis [4], they were meant to be applied to patients with “suspected infection”, just as the qSOFA is intended to be used now. However, while the SIRS criteria were essentially based only on expert-consensus [4], the qSOFA criteria were identified through large multivariate statistics and confirmatory analyses, where they proved to perform better than the SIRS criteria [3]. The qSOFA was derived and conceived on the basis of retrospective data, and thus, from now on, the clinical research should and will work hard to prospectively validate the soundness of this tool, in terms of its screening capacity. However, based at least on the currently available evidence, we believe that, although qSOFA does not replace SIRS in the definition of sepsis, it should indeed replace SIRS as the screening tool for sepsis. We would like to know if Vincent and colleagues agree with this assumption, and we would also like to ask them if, after the Sepsis-3 consensus definitions, the SIRS criteria still retain a real operative role in the process of defining and/or screening sepsis or if they could be, at least operatively, dismissed.

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qSOFA does not replace SIRS in the definition of sepsis

Jean-Louis Vincent, Greg Martin, Mitchell Levy (2016)

The recently published consensus definitions for sepsis [1] have raised a lot of discussion and controversy. We had the privilege of being part of this consensus group and fully support the final definitions. We are pleased that a definition has been developed that closely reflects everyday clinical language, recognizing that sepsis is most simply described as a “bad infection” associated with some degree of organ dysfunction, as proposed earlier [2]. The article conveying the consensus definition [1] also emphasizes that sepsis is more often recognized from the associated organ dysfunction than from the more difficult to identify infection, so that sepsis can be defined as “life-threatening organ dysfunction caused by a dysregulated host response to an infection”. The proposition of the 1992 North American consensus document [3] that sepsis be defined by a combination of the systemic inflammatory response syndrome (SIRS) and the presence of an infection raised confusion, because the SIRS criteria (especially fever, tachycardia, and altered white blood cell count) are themselves typical features of infection [3]. As the majority of infected patients will therefore meet the SIRS criteria, they would also be considered to have sepsis by this 1992 definition. This approach to defining sepsis has resulted in a dramatic increase in the number of patients diagnosed with sepsis over the years [4]; however, these patients may have less severe disease so that reported parallel reductions in mortality rates [5] may be deceptive [6]. The recent “new” definitions are not so novel, more a return to the traditional use of the term to indicate patients with a substantial and deleterious response to an infection. We doubt that this will change further over time, exactly as the meaning of other words like pneumonia, peritonitis, or meningitis has not changed. We all agree on the fundamental importance of identifying sepsis early and of applying effective and complete treatment to minimize complications. However, the SIRS criteria were too sensitive and not sufficiently specific for this purpose. Rangel-Frausto et al. [7] reported that 68 % of patients admitted to three intensive care units (ICUs) and three general wards met the SIRS criteria; in 198 ICUs in 24 European countries, Sprung et al. [8] reported that 93 % of ICU patients had at least two SIRS criteria at some point during their ICU stay; and in a database of patients in 23 Australian and New Zealand ICUs, Dulhunty et al. [9] reported that 88.4 % of patients had at least two SIRS criteria on ICU admission. In a recent analysis of a large US database, Churpek et al. [10] reported that almost half of the 270,000 patients hospitalized on regular wards met the SIRS criteria at one time or another. Our consensus definition paper suggested the quick sequential organ failure assessment (qSOFA) as an effective way of raising suspicion of sepsis on the regular floor [1]. Evaluating all six components of the SOFA score can be time consuming, and some require laboratory measurements. By analyzing a large database of hospitalized patients, three clinical elements (hypotension, altered mentation, and tachypnea) were identified that could be used at the bedside to recognize those infected patients who are at risk of deteriorating or having a complicated course (death or ICU stay ≥ 3 days). The presence of two or more of these criteria can be used to prompt clinicians to further evaluate the patient for the presence of infection and/or organ dysfunction, to start or adapt treatment, and to consider transfer to an ICU. Importantly, this approach is designed to be an early warning system, and a patient with less than two qSOFA criteria may still raise concern. Clinical judgment should always supersede tools designed to help improve patient care, such as qSOFA. We would like to stress that, although SIRS was part of the definition of sepsis in 1992 [3], the qSOFA is not part of the new sepsis definitions. This important difference is illustrated in Fig. 1, with panel A showing that infection and sepsis (by the 1992 definition) are virtually the same—infection without SIRS can be found, but it is relatively rare. By contrast, panel B shows that sepsis (by the new SEPSIS-3 definition) represents only a minority of cases of infection. Moreover, panel B illustrates important aspects of the sepsis definition vis-à-vis infection and qSOFA. For example, sepsis can be present without a qSOFA score ≥ 2 because different forms of organ dysfunction may be present than are assessed using the qSOFA, such as hypoxemia, renal failure, coagulopathy, or hyperbilirubinemia. In addition, a patient may have a qSOFA ≥ 2 without infection; for example, in other acute conditions, such as hypovolemia, severe heart failure, or large pulmonary embolism. Further work remains to be done to determine the predictive validity of qSOFA in such patients. Finally, infected patients may have a qSOFA ≥ 2 and not be septic because the degree of hypotension, tachycardia, and/or altered mentation needed to fulfill qSOFA criteria is not the same as that needed to meet the SOFA organ dysfunction criteria necessary for a diagnosis of sepsis; the qSOFA criteria are thus clinically valuable but imperfect markers of sepsis. Nevertheless, in an analysis of a database of more than 74,000 patients, Seymour et al. [11] recently reported that 75 % of patients with suspected infection who had two or more qSOFA points also had at least two SOFA points. Fig. 1 Schematic representation illustrating a the almost complete overlap of sepsis and infection when the SIRS criteria of the 1992 criteria [3] are used and b the differences between qSOFA and sepsis. qSOFA quick sequential organ failure assessment, SIRS systemic inflammatory response syndrome We hope this editorial will clarify that the qSOFA is meant to be used to raise suspicion of sepsis and prompt further action—it is not a replacement for SIRS and is not part of the definition of sepsis. Abbreviations ICU, intensive care unit; qSOFA, quick sequential organ failure assessment; SIRS, systemic inflammatory response syndrome; SOFA, sequential organ failure assessment.

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Contributors

Stefano Franchini: 00390226435638 , franchini.stefano@hsr.it

Andrea Duca: 00390226435638 , andreaduca@hotmail.com

Journal

Journal ID (nlm-ta): Crit Care

Title: Critical Care

Publisher: BioMed Central (London )

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Electronic): 28 December 2016

Publication date PMC-release: 28 December 2016

Publication date Collection: 2016

Volume: 20

Electronic Location Identifier: 409

Affiliations

Emergency Department, Ospedale San Raffaele Scientific Institute, Via Olgettina 60, Milan, 20132 Italy

Article

Publisher ID: 1562

DOI: 10.1186/s13054-016-1562-4

PMC ID: 5192569

PubMed ID: 28027712

SO-VID: 00d16548-7272-459b-a9c3-1f39b18199f7

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 6 September 2016

Date accepted : 8 November 2016

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ScienceOpen disciplines: Emergency medicine & Trauma

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ScienceOpen disciplines: Emergency medicine & Trauma

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