Application of the Third International Consensus Definitions for Sepsis (Sepsis-3) Classification: a retrospective population-based cohort study

Abstract

BACKGROUND The Third International Consensus Definitions for Sepsis (Sepsis-3) present clinical criteria for classifying infection patients. Event incidence and long-term outcomes across these classifications are unknown. METHODS We conducted a retrospective analysis using data from 30,239 US participants aged ≥45 years enrolled in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. We identified hospitalizations over 2003–2012 using three classifications: infection with systemic inflammatory response syndrome (SIRS), elevated sepsis-related organ failure assessment score (SOFA), or elevated “quick” SOFA (qSOFA) score. We examined incidence over the study period, in-hospital mortality, and one-year mortality, providing estimates and 95% confidence intervals (CIs). FINDINGS Among 2,593 infection events, there were 1,526 sepsis-SIRS, 1,080 sepsis-SOFA, and 378 sepsis-qSOFA events. Sepsis-SIRS events had the highest incidence (8.2 per 1,000 person-years; 95% CI 7.8–8.7), followed by sepsis-SOFA (5.8; CI 5.4–6.1) and sepsis-qSOFA (2.0; CI 1.8–2.2). In-hospital mortality was higher for sepsis-qSOFA (67/295; 22.7%) than sepsis-SOFA (125/960; 13.0%) and sepsis-SIRS (128/1,392; 9.2%). One-year mortality post-discharge was also highest for sepsis-qSOFA (29.4 per 100 person-years; CI 22.3–38.7) compared to sepsis-SOFA (22.6; CI 19.2–26.6) and sepsis-SIRS (14.7; CI 12.5–17.2). INTERPRETATION The examined classifications identified different incidence and mortality. Our findings support the use of the sepsis-SOFA and sepsis-qSOFA classifications for identification of infection patients at elevated risk of poor outcomes. We also demonstrate how these classifications could be used in future epidemiological assessments and studies of patients with infection. FUNDING National Institute for Nursing Research (R01-NR012726), National Center for Research Resources (UL1-RR025777), and National Institute of Neurological Disorders and Stroke (U01-NS041588). JPD held an Agency for Healthcare Research and Quality predoctoral fellowship (T32-HS013852). MMS was supported by a mentoring award from the National Heart, Lung and Blood Institute (K24-HL111154).

Modified Sequential Organ Failure Assessment sepsis score in an emergency department setting: Retrospective assessment of prognostic value

“…showed the SOFA was predictive of outcome in ED patients with borderline or confirmed septic shock . More recent retrospective studies using large cohorts have shown SOFA performed well in community stroke patients and using qSOFA in ED . Conversely, the SOFA score was very effective in identifying those with suspected sepsis in ED who had a low mortality risk (negative predictive value 97.9% for 30 day mortality).…”

“…SOFA has been most well known and applicable to the critical care community . As yet there have been relatively few reports of clinical use of the SOFA score in the ED setting, especially in undifferentiated patients with suspected sepsis . The quick SOFA (qSOFA) score is more readily applied in ED and experience with its use in the pre‐hospital setting is emerging, but qSOFA may be insufficiently sensitive, in particular because acute renal dysfunction that is common in sepsis is not included in qSOFA in contrast to the SOFA score …”

“…2,3 As yet there have been relatively few reports of clinical use of the SOFA score in the ED setting, especially in undifferentiated patients with suspected sepsis. [4][5][6][7] The quick SOFA (qSOFA) score is more readily applied in ED and experience with its use in the pre-hospital setting is emerging, but qSOFA may be insufficiently sensitive, in particular because acute renal dysfunction that is common in sepsis is not included in qSOFA in contrast to the SOFA score. 3,6 The mortality of those admitted to intensive care units (ICUs) with sepsis has decreased over recent years, which likely reflects a combination of improved ICU care and selection of patients more likely to benefit.…”

Revised National Estimates of Emergency Department Visits for Sepsis in the United States*

“…However, in the context of this epidemiologic study, the similar outcomes between qSOFA and non-qSOFA sepsis cases may actually be a strength, supporting the use of qSOFA as an additional strategy for identifying sepsis cases. We have previously illustrated the utility of qSOFA in characterizing community-acquired sepsis susceptibility and mortality (23). We note that ED Sepsis cases fulfilling both Original and qSOFA criteria exhibited higher rates of ICU admission than those with either criteria alone, suggesting synergy between the two classification approaches.…”

In the Literature

“…In an examination of 2593 first infection events recorded in a large US database, 1526 met SIRS criteria, whereas criteria for SOFA and qSOFA were met by 1080 and 378, respectively, with corresponding mortality rates of 9%, 13%, and 23%, respectively [2].…”