There is no gold standard for sepsis diagnosis. Therefore, this study evaluated the performance of Sepsis-1 and Sepsis-3 definitions in predicting the 30-day mortality using ROC curves. The AUROC of the Sepsis-3 model with regard to the 30-day mortality rates was 0.746 (0.710–0.783). However, the AUROC of the Sepsis-1 model (0.620 [0.577–0.663]) was significantly lower than that of the Sepsis-3 model (0.746 [0.710–0.783], P < 0.01; Table 3). Additionally, the sensitivity (72.8%) and the specificity (69.0%) of the Sepsis-3 model with respect to the 30-day mortality were higher than those of the Sepsis-1 model (63.3% and 57.8%, respectively).
We also evaluated the performance of SIRS, qSOFA, and SOFA in predicting the 30-day mortality using ROC curves. The results showed that the AUROC of SIRS and qSOFA with regard to the 30-day mortality were 0.609 (0.566–0.652) and 0.694 (0.654–0.733), respectively. However, the AUROC of SOFA (0.828 [0.795–0.862]) was significantly higher than that of SIRS (0.609 [0.566–0.652]) or qSOFA (0.694 [0.654–0.733]; all P < 0.001) [Figure 3].
A higher specificity and a better distinction between sepsis and non-sepsis have always been demanded in the past. In the present study, 85.9% of the patients with suspected infections admitted to the ICUs met the Sepsis-1 definition. A total of 22.6% of the patients were diagnosed with sepsis according to the Sepsis-1 definition but were excluded according to the Sepsis-3 definition, which differed from a previous study. The main probable reason was that the patients included in this study were different from those in the previous study. All patients in this study were admitted to the ICU, while only 37.5% of patients in the study of Cheng et al were admitted to the ICU. Furthermore, according to the Sepsis-3 definition, 64.5% of the suspected infection patients were diagnosed with sepsis. Thus, relative to the results with the Sepsis-1 definitions, fewer patients with suspected infection were classified as having sepsis according to the Sepsis-3 definitions. Additionally, this study indicated that sepsis patients as defined by the Sepsis-3 definitions had a higher mortality rate. Therefore, the findings supported the use of the Sepsis-3 definition to identify critically ill patients with suspected infection who are at high risk of death.
Previous studies indicated that the number of SIRS criteria present could not be used to stratify the severity of illness.[9–10,19–20] The Sepsis-3 definition exclude the concept of SIRS since this term is no longer considered useful.[21–22] The SOFA and qSOFA scores have been used as two diagnostic tools to identify sepsis with the Sepsis-3 definition.[3–4] We further evaluated the performance of SIRS and qSOFA and SOFA scores using an ROC curve to predict the 30-day mortality. The AUROC of SIRS and qSOFA scores with regard to 30-day mortality rates were 0.609 (0.566–0.652) and 0.694 (0.654–0.733), respectively. However, the AUROC of SOFA scores (0.828 [0.795–0.862]) was significantly higher than that of SIRS or qSOFA scores. This meant that the SOFA score was an excellent tool and superior to SIRS or the qSOFA score for predicting mortality in critically ill patients with suspected infection.
The present study had strength and some limitations. The strength was that the size of the cohort was relatively large. Our study had several limitations. First, we followed our patients for only 30 days and did not collect data beyond that point. Long-term survival rates will be explored in the future. Second, we evaluated only patients admitted to the ICU; thus, our findings could not be generalized to patients treated in regular wards and in the emergency room. Third, the validity of the Sepsis-3 definition in this study was assessed based on the 30-day mortality. Although the 30-day mortality is widely used, the 28-day mortality and ICU mortality were used as endpoints in some studies, possibly causing deviations in results among studies.[14–15,23–25]
In conclusion, this study showed that the new clinical criteria of sepsis proposed in the Sepsis-3 definitions predicted the 30-day mortality in adult critically ill patients with suspected infection. The Sepsis-3 definition was relatively accurate and superior to the Sepsis-1 definition in stratifying mortality. Our findings supported the translation of the Sepsis-3 definitions into sepsis definitions in adult critically ill patients with suspected infection.
This study was supported by grants from Social Development Funds of Jiangsu Province (No. BE2017691), National Natural Science Foundations of China (No. 81670065), and Social Development Funds of Yangzhou City (No. YZ2017086).
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