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Composition of the Sepsis Definitions Task Force--Reply.

That is not the case. Rather, SIRS may be useful in the presumptive diagnosis of infection. However, SIRS is not specific nor particularly sensitive for infection. As an example, Churpek and colleagues1 reported that 50% of hospital inpatients have SIRS at least once in their hospital stay, and many of these patients will not have infection nor require antibiotic therapy. Conversely, 64% of the 66 522 non–intensive care unit (ICU) patients in the University of Pittsburgh Medical Center validation cohort had 0 or 1 SIRS criteria at the time they were cultured and treated for suspected infection. The article also did not suggest that what was previously called “sepsis” be eliminated from the diagnostic spectrum. Rather, it should be simply and correctly identified as “infection.” We are surprised by the concern expressed by these authors and Dr Townsend and colleagues that the new definitions will delay the diagnosis of sepsis and negatively affect survival. Treatment should not be delayed until patients deteriorate to fulfill 2 or more qSOFA criteria. We would expect management to be similar to that provided to the 1 in 8 infected patients with new-onset organ failure who were admitted to Australasian ICUs despite having fewer than 2 SIRS criteria and previously would not have qualified as “septic.”2 The new criteria were based on analysis of more than 850 000 hospitalized patients with suspected infection.3 Such an exercise has not previously been undertaken and SIRS has never been scrutinized so comprehensively. This analysis underpinned the development of the qSOFA criteria for rapid assessment of patients with suspected infection likely to have poor outcomes. Both SIRS and qSOFA were compared using data abstracted from varying time windows both before and after cultures were sent and antibiotics started. In this analysis, qSOFA showed superior predictive validity. Nonetheless, we encourage prospective confirmation of these findings in different health care settings. We are also unaware of any prospective interventional studies using SIRS alone as an entry criterion. All the cited studies showing mortality benefits through quality improvement programs involved patients who had established organ dysfunction (ie, “sepsis” in the new definition). To die from infection requires development of organ dysfunction; therefore the new definition cannot increase absolute mortality. The large increase in discharge coding for sepsis4 has lowered relative mortality but increased absolute numbers of patients dying. This trend was observed irrespective of the coding method used, but the choice of method affected estimates of incidence and absolute mortality. A major aim of the new definitions is to reduce this inconsistency. Townsend and colleagues share the concerns of CMS about the new definitions. We are encouraged that CMS will track and test application of a SOFA score of 2 or greater and qSOFA. Multiple groups worldwide are already engaged in this process. We are confident that this measured approach will lead to a reconciliation of any differences with existing quality improvement parameters, improving the care of septic patients. We agree with Dr Singh and colleagues that an updated SOFA score should be developed as part of the next iteration of the definitions. The SOFA score simply records vasopressor usage and dosage that are decided at the local (hospital) level, notwithstanding consensus recommendations. Rather than discouraging efforts to detect sepsis early in its course, as voiced by Schneider-Lindner and colleagues, the new definition specifically highlights the 2 key characteristics of sepsis—namely, organ dysfunction and a dysregulated host response. Use of this new definition should lead researchers to focus on developing early, more-sensitive means to detect the presence of these 2 key components that differentiate infection from sepsis.