[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Torio  CM, Andrews  RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Statistical Brief #160. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. August 2013. http://www.ncbi.nlm.nih.gov/books/NBK169005/. Accessed October 31, 2015.
Iwashyna  TJ, Cooke  CR, Wunsch  H, Kahn  JM.  Population burden of long-term survivorship after severe sepsis in older Americans.  J Am Geriatr Soc. 2012;60(6):1070-1077.PubMedGoogle ScholarCrossref
Gaieski  DF, Edwards  JM, Kallan  MJ, Carr  BG.  Benchmarking the incidence and mortality of severe sepsis in the United States.  Crit Care Med. 2013;41(5):1167-1174.PubMedGoogle ScholarCrossref
Dellinger  RP, Levy  MM, Rhodes  A,  et al; Surviving Sepsis Campaign Guidelines Committee Including the Pediatric Subgroup.  Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012.  Crit Care Med. 2013;41(2):580-637.PubMedGoogle ScholarCrossref
Rhee  C, Gohil  S, Klompas  M.  Regulatory mandates for sepsis care—reasons for caution.  N Engl J Med. 2014;370(18):1673-1676.PubMedGoogle ScholarCrossref
Vincent  J-L, Marshall  JC, Namendys-Silva  SA,  et al; ICON Investigators.  Assessment of the worldwide burden of critical illness: the Intensive Care Over Nations (ICON) audit.  Lancet Respir Med. 2014;2(5):380-386.PubMedGoogle ScholarCrossref
Fleischmann  C, Scherag  A, Adhikari  NK,  et al; International Forum of Acute Care Trialists.  Assessment of global incidence and mortality of hospital-treated sepsis: current estimates and limitations.  Am J Respir Crit Care Med. 2015. PubMedGoogle Scholar
Iwashyna  TJ, Ely  EW, Smith  DM, Langa  KM.  Long-term cognitive impairment and functional disability among survivors of severe sepsis.  JAMA. 2010;304(16):1787-1794.PubMedGoogle ScholarCrossref
Bone  RC, Balk  RA, Cerra  FB,  et al.  American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.  Crit Care Med. 1992;20(6):864-874.PubMedGoogle ScholarCrossref
Levy  MM, Fink  MP, Marshall  JC,  et al; International Sepsis Definitions Conference.  2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.  Intensive Care Med. 2003;29(4):530-538.PubMedGoogle ScholarCrossref
Vincent  J-L, Opal  SM, Marshall  JC, Tracey  KJ.  Sepsis definitions: time for change.  Lancet. 2013;381(9868):774-775.PubMedGoogle ScholarCrossref
Seymour  CW, Liu  V, Iwashyna  TJ,  et al Assessment of clinical criteria for sepsis.   JAMA. doi:10.1001/jama.2016.0288.Google Scholar
Shankar-Hari  M, Phillips  G, Levy  ML,  et al Assessment of definition and clinical criteria for septic shock.  JAMA.doi:10.1001/jama.2016.0289Google Scholar
Angus  DC, van der Poll  T.  Severe sepsis and septic shock.  N Engl J Med. 2013;369(9):840-851.PubMedGoogle ScholarCrossref
Wiersinga  WJ, Leopold  SJ, Cranendonk  DR, van der Poll  T.  Host innate immune responses to sepsis.  Virulence. 2014;5(1):36-44.PubMedGoogle ScholarCrossref
Hotchkiss  RS, Monneret  G, Payen  D.  Sepsis-induced immunosuppression: from cellular dysfunctions to immunotherapy.  Nat Rev Immunol. 2013;13(12):862-874.PubMedGoogle ScholarCrossref
Deutschman  CS, Tracey  KJ.  Sepsis: current dogma and new perspectives.  Immunity. 2014;40(4):463-475.PubMedGoogle ScholarCrossref
Singer  M, De Santis  V, Vitale  D, Jeffcoate  W.  Multiorgan failure is an adaptive, endocrine-mediated, metabolic response to overwhelming systemic inflammation.  Lancet. 2004;364(9433):545-548.PubMedGoogle ScholarCrossref
Hotchkiss  RS, Swanson  PE, Freeman  BD,  et al.  Apoptotic cell death in patients with sepsis, shock, and multiple organ dysfunction.  Crit Care Med. 1999;27(7):1230-1251.PubMedGoogle ScholarCrossref
Kwan  A, Hubank  M, Rashid  A, Klein  N, Peters  MJ.  Transcriptional instability during evolving sepsis may limit biomarker based risk stratification.  PLoS One. 2013;8(3):e60501.PubMedGoogle ScholarCrossref
Iskander  KN, Osuchowski  MF, Stearns-Kurosawa  DJ,  et al.  Sepsis: multiple abnormalities, heterogeneous responses, and evolving understanding.  Physiol Rev. 2013;93(3):1247-1288.PubMedGoogle ScholarCrossref
Wong  HR, Cvijanovich  NZ, Anas  N,  et al.  Developing a clinically feasible personalized medicine approach to pediatric septic shock.  Am J Respir Crit Care Med. 2015;191(3):309-315.PubMedGoogle ScholarCrossref
Langley  RJ, Tsalik  EL, van Velkinburgh  JC,  et al.  An integrated clinico-metabolomic model improves prediction of death in sepsis.  Sci Transl Med. 2013;5(195):195ra95.PubMedGoogle ScholarCrossref
Chan  JK, Roth  J, Oppenheim  JJ,  et al.  Alarmins: awaiting a clinical response.  J Clin Invest. 2012;122(8):2711-2719.PubMedGoogle ScholarCrossref
Churpek  MM, Zadravecz  FJ, Winslow  C, Howell  MD, Edelson  DP.  Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients.  Am J Respir Crit Care Med. 2015;192(8):958-964.PubMedGoogle ScholarCrossref
Kaukonen  K-M, Bailey  M, Pilcher  D, Cooper  DJ, Bellomo  R.  Systemic inflammatory response syndrome criteria in defining severe sepsis.  N Engl J Med. 2015;372(17):1629-1638.PubMedGoogle ScholarCrossref
Vincent  JL, Moreno  R, Takala  J,  et al; Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine.  The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure.  Intensive Care Med. 1996;22(7):707-710.PubMedGoogle ScholarCrossref
Vincent  JL, de Mendonça  A, Cantraine  F,  et al; Working Group on “Sepsis-Related Problems” of the European Society of Intensive Care Medicine.  Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study.  Crit Care Med. 1998;26(11):1793-1800.PubMedGoogle ScholarCrossref
Rubulotta  FM, Ramsay  G, Parker  MM, Dellinger  RP, Levy  MM, Poeze  M; Surviving Sepsis Campaign Steering Committee; European Society of Intensive Care Medicine; Society of Critical Care Medicine.  An international survey: public awareness and perception of sepsis.  Crit Care Med. 2009;37(1):167-170.PubMedGoogle ScholarCrossref
Le Gall  J-R, Klar  J, Lemeshow  S,  et al; ICU Scoring Group.  The Logistic Organ Dysfunction system: a new way to assess organ dysfunction in the intensive care unit.  JAMA. 1996;276(10):802-810.PubMedGoogle ScholarCrossref
Shah  RU, Henry  TD, Rutten-Ramos  S, Garberich  RF, Tighiouart  M, Bairey Merz  CN.  Increasing percutaneous coronary interventions for ST-segment elevation myocardial infarction in the United States: progress and opportunity.  JACC Cardiovasc Interv. 2015;8(1 pt B):139-146.PubMedGoogle ScholarCrossref
Kraut  JA, Madias  NE.  Lactic acidosis.  N Engl J Med. 2014;371(24):2309-2319.PubMedGoogle ScholarCrossref
Casserly  B, Phillips  GS, Schorr  C,  et al.  Lactate measurements in sepsis-induced tissue hypoperfusion: results from the Surviving Sepsis Campaign database.  Crit Care Med. 2015;43(3):567-573.PubMedGoogle ScholarCrossref
Cecconi  M, De Backer  D, Antonelli  M,  et al.  Consensus on circulatory shock and hemodynamic monitoring. Task Force of the European Society of Intensive Care Medicine.  Intensive Care Med. 2014;40(12):1795-1815.PubMedGoogle ScholarCrossref
Czura  CJ.  “Merinoff symposium 2010: sepsis”—speaking with one voice.  Mol Med. 2011;17(1-2):2-3.PubMedGoogle ScholarCrossref
Ait-Oufella  H, Bige  N, Boelle  PY,  et al.  Capillary refill time exploration during septic shock.  Intensive Care Med. 2014;40(7):958-964.PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    3 Comments for this article
    International Consensus Definitions for Sepsis and Septic Shock
    Phoebe Atieno RN, MHA | Sepsis Data Manager
    After reading your article, I looked at your definitions and that of CMS. It seems to me that the overarching idea for your article was to increase responsiveness and identify patients who have sepsis or might have sepsis in a timely manner to improve outcomes. It also seems that while CMS uses the bundle approach to organize the care, your article advocates for SOFA and QSOFA to help identify and care for this patients. Having been in healthcare for a few years, it seems to me that using the term "severe" might elicit certain quick actions to be implemented as opposed to not using that term as your article suggests that the term "severe sepsis" is redundant. Would you please comment on that?

    Author Reply
    Mervyn Singer, MD, FRCP | Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom
    Thank you for your question. As a clinician I’ve never heard anyone proclaim at the bedside or by a phone referral that a patient has ‘severe sepsis.’ They are merely called ‘septic’. 'Severe sepsis' is reserved for coding, epidemiology, and for fulfilling entry criteria into research studies. The problem then arises with the old definitions that everyone who has suspected infection + SIRS becomes ‘septic’ regardless of whether they’re sick or not. With the new definitions we tried to distinguish between a routine uncomplicated infection and the sicker variety which leads to organ dysfunction. So ’septic’ in the new terminology should indicate concern.
    CONFLICT OF INTEREST: Dr Singer reports serving on the advisory boards of InflaRx, Bayer, Biotest, and Merck and that his institution has received grants from the European Commission, UK National Institute of Health Research, Immunexpress, DSTL, and Wellcome Trust.
    Definition of "Bands"
    Eddie Ferguson, BS Microbiology, MT(ASCP) | Industry Hematology Applications Specialist Representative
    Thanks so much to Dr. Singer, et al for all their hard work on developing Consensus Definitions for Sepsis and Septic Shock.

    Box 1 states that a criterion for SIRS is >"10% immature bands."

    However, nowhere in the Consensus Definitions does it define what a "band" is.

    The published literature specifically addressing "bands" since approximately 1990 has discussed the inconsistent agreement on what a "band" is.

    The CAP (College of American Pathologists) has been on the forefront of deemphasizing the use of "bands" because of the disagreement on the definition of "bands."

    CAP has for
    several years - as part of their quarterly morphology survey challenges - does not distinguish between "segs" or "bands."

    I appreciate any feedback and would ask special consideration be given to how "bands" are defined and perhaps consider a change in this specific criteria.

    Thank you very much,

    Eddie Ferguson, MT(ASCP)

    Special Communication
    Caring for the Critically Ill Patient
    February 23, 2016

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

    Author Affiliations
    • 1Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom
    • 2Hofstra–Northwell School of Medicine, Feinstein Institute for Medical Research, New Hyde Park, New York
    • 3Department of Critical Care and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
    • 4Department of Critical Care Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
    • 5Department of Critical Care Medicine, University of Versailles, France
    • 6Center for Sepsis Control and Care, University Hospital, Jena, Germany
    • 7Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, and Austin Hospital, Melbourne, Victoria, Australia
    • 8Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University, Nashville, Tennessee
    • 9Réanimation Médicale-Hôpital Cochin, Descartes University, Cochin Institute, Paris, France
    • 10Critical Care Center, Emory University School of Medicine, Atlanta, Georgia
    • 11Washington University School of Medicine, St Louis, Missouri
    • 12Infectious Disease Section, Division of Pulmonary and Critical Care Medicine, Brown University School of Medicine, Providence, Rhode Island
    • 13Department of Surgery, University of Toronto, Toronto, Ontario, Canada
    • 14Emory University School of Medicine and Grady Memorial Hospital, Atlanta, Georgia
    • 15Trauma, Emergency & Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
    • 16Interdepartmental Division of Critical Care, University of Toronto
    • 17Department of Infectious Diseases, Academisch Medisch Centrum, Amsterdam, the Netherlands
    • 18Department of Intensive Care, Erasme University Hospital, Brussels, Belgium
    • 19Department of Critical Care Medicine, University of Pittsburgh and UPMC Health System, Pittsburgh, Pennsylvania
    • 20Associate Editor, JAMA
    JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

    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.