||Expert Commentary: ACPA members were very divided in the approach to defining sepsis, further underscoring Dr. Antonios' point of the need for a better sepsis definition. However, the current sepsis definition is that defined by Sepsis-3 - life threatening organ dysfunction caused by a dysregulated host response to infection. That is the definition that everyone should be currently following, but clearly that is not happening yet. Why? There are several reasons:
- A perception that sepsis-3 recognizes sepsis "too late" and that early SIRS based recognition can lead to better outcomes. This perception, however, if flawed because any prospective study that demonstrated survival benefit in sepsis did it in patients with SIRS + organ dysfunction, not merely SIRS alone. The sepsis-3 authors are contending that organ dysfunction, rather than SIRS criteria, is the important piece to recognize early. However, studies to evaluate sepsis survival using SOFA or qSOFA as the clinical recognition tool are not yet available. Preliminary studies so far do indicate that SOFA and qSOFA are better at predicting mortality than SIRS.
- Surviving Sepsis Guidelines from 2012 were based on Sepsis-2, and form the basis of most current recognition and treatment regimens, including the CMS SEP-1 bundle. While the Surviving Sepsis Guidelines were rewritten in 2017 to reflect Sepsis-3, the CMS bundle has not changed. In an editorial published in JAMA, CMS responded to the Sepsis-3 guidelines with great reservation and indicated no intention to change the SEP-1 bundle sepsis definition anytime soon.
- Payors are variable as to whether they follow Sepsis-2 or Sepsis-3 guidelines
- SOFA is an old construct and requires information not always available (such as an ABG). In addition, the "Clinical Criteria" in the Sepsis-3 paper use a SOFA change of 2 or greater from baseline, but the Clinical Criteria are not the sepsis definition - which remains the yet unmeasurable "life threatening organ dysfunction caused by a dysregulated host response to infection."
- Several clinical governing bodies complained about not being included in the international sepsis-3 consensus panel.
With time, we expect the use of the Sepsis-3 definition and the Sepsis-3 constructs (SOFA and qSOFA) to be more widely adopted by providers and payors. A lot will depend on the clinical research studies using those constructs, and whether they are able to decrease sepsis mortality compared to current care.