Importance Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination. Objective To evaluate and, as needed, update definitions for sepsis and septic shock. Process A task force (n = 19) with expertise in sepsis pathobiology, clinical trials, and epidemiology was convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Definitions and clinical criteria were generated through meetings, Delphi processes, analysis of electronic health record databases, and voting, followed by circulation to international professional societies, requesting peer review and endorsement (by 31 societies listed in the Acknowledgment). Key Findings From Evidence Synthesis Limitations of previous definitions included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality. The task force concluded the term severe sepsis was redundant. Recommendations Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. Conclusions and Relevance These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.

https://jamanetwork.com/journals/jama/articlepdf/2492881/jsc160002.pdf

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

https://journal.chestnet.org/article/S0012-3692(16)38415-X/pdf

Definitions for Sepsis and Organ Failure and Guidelines for the Use of Innovative Therapies in Sepsis

According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

Background Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit. Methods We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups. Results Of the 263 enrolled patients, 130 were ...

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock

ObjectiveTo determine the incidence, cost, and outcome of severe sepsis in the United States.DesignObservational cohort study.SettingAll nonfederal hospitals (n = 847) in seven U.S. states.PatientsAll patients (n = 192,980) meeting criteria for severe sepsis based on the International Classification

Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care.

In Reply. —We agree with the argument that sepsis as defined by the American College of Chest Physicians—Society of Critical Care Medicine Consensus Conference1is a form of SIRS and not specifically an initial stage of the dynamic process of infection. However, it was our hypothesis that SIRS could define the population at risk for sepsis based on the suggestions of the members of the conference. In our study, SIRS was frequently the initial stage for the subgroup of patients who subsequently developed sepsis or a more serious SIRS. More importantly, the interval to sepsis was carefully measured and was progressively shorter as more clinical criteria for SIRS were met. Such data are useful clinically. As stated by Dr Balk, some patients in the study had SIRS, and empirical antimicrobial treatment was prescribed by their physicians for presumed but never documented infection. We elected to quantify this group because they

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=389176&pdfFileName=jama_274_2_022.pdf

The Systemic Inflammatory Response Syndrome-Reply

Book Review The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers Second edition. By Stuart B. Levy. 353 pp., illustrated. Cambridge, Mass., Perseus Publishing, 2002. $17.50. 0-7382-0440-4

A brief historical review of hospital surveillance data is presented. It is suggested that routine surveillance of nosocomial infections is important to identify problems for correction, to order priorities, and to influence rates favorably.

Is there infection control without surveillance

The prevalence of hospital-acquired, antibiotic-resistant organisms has increased significantly over the last 20 years. Data from the National Healthcare Safety Network (NHSN) report published in 2013 revealed an alarming proportion of drug-resistant pathogens [1]. The NHSN system report represents data from more than 4000 medical facilities throughout the United States. Reports of hospital-acquired infections and microbiology data from participating institutions are published annually. From the sample, in 2009–2010, 43.7–58.7 % of all S. aureus isolates were resistant to methicillin, depending on the site of infection. Enterococcus faecalis and Enterococcus faecium were 6.2–9.8 % and 62.3–82.6 % vancomycin resistant, respectively [1]. An increase in drug-resistant staphylococci and enterococci has also been reported in Europe and South America [2–4].

Richard P. Wenzel

Papers

The Systemic Inflammatory Response Syndrome-Reply

Book Review The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers Second edition. By Stuart B. Levy. 353 pp., illustrated. Cambridge, Mass., Perseus Publishing, 2002. $17.50. 0-7382-0440-4

Is there infection control without surveillance

Hospital Infection Control: Considerations for the Management and Control of Drug-Resistant Organisms

300 – Infection Prevention in the Health Care Setting