Sepsis Screening Tools in the Era of Sepsis 3.0

To the Editor:

We read with great interest the review article by Villegas et al. [1], who aimed to summarize the current evidence and available tools for sepsis screening. Although the study sounds scientific, we have some different viewpoints that should be addressed.

First, there are some inaccuracies in the review. In fact, the study cited in the last row of Table 1 should be “Goerlich et al. (2014) [17]” rather than “Goerlich et al. (2014) [14]. This small error might have been introduced by the copyeditor rather than the authors, but in any case, it requires correction.

Second, Villegas et al. [1] quoted the study carried out by Haydar et al. [2] to support their viewpoint. However, as we have pointed out previously [3], this study is per se incorrect, as quick sequential sepsis-related organ failure assessment (qSOFA) consists of only three elements: Ventilatory rate, altered mental status, and systolic blood pressure. The calculation time of this score will be no more than 10 min. Thus, we believe that the time required to calculate qSOFA will not be longer than the time for assessing the systemic inflammatory response syndrome (SIRS), and we cannot understand why it takes an average of 84.0 minutes from the arrival of the patient to SIRS documentation in the study by Haydar et al. [2].

Third, 25 years elapsed from the first definition of sepsis (Sepsis 1.0) in 1991 to the third definition (Sepsis 3.0) in 2016. As Table 1 in the paper indicates, there was only one study published after 2016; another five studies investigating sepsis screening tools all were published before 2016. Nevertheless, the 2016 study (carried out by Wawrose et al.) still applied Sepsis 1.0 rather than Sepsis 3.0, which meant no studies in this review investigated the screening tools to be used for Sepsis 3.0. We thus are concerned that this review may not be comprehensive. As a matter of fact, the Sepsis 3.0 definition study proposed a new bedside clinical score termed qSOFA, which could facilitate earlier recognition and timely management of septic patients outside the intensive care unit. Afterwards, a multicenter study [4] put forward another new screening tool combining lactate values with qSOFA, which could improve further the test's utility in screening emergency department patients presenting with suspected sepsis.

Finally, Villegas et al. [1] disagreed with the use of organ dysfunction criteria in the identification of sepsis, claiming that patients might have progressed beyond sepsis by the time organ dysfunction begins to appear. However, the definition of sepsis proposed by Sepsis 3.0 includes the statement that sepsis is “life-threatening organ dysfunction caused by a dysregulated host response to infection,” which means that if there are no signs of organ dysfunction, there is no sepsis! Actually, organ dysfunction should be the core of sepsis definition, as it can result in a considerable number of deaths. What we should do is recognize those septic patients in the early stage (when the organ dysfunction is mild) or those who have a chance of developing sepsis, although significant challenges remain in developing the optimal screening tools. Further research is warranted.