Wow! This article explains wonderfully the problem of guidelines. Confirmation bias will impact all guideline panel members. As you read the IDSA explanations, you can see that they have focused on the unintended consequences of markedly increasing sensitivity and therefore markedly decreasing specificity. The reference for the IDSA article (abstract only unless you have access).
The main points are found in the report – IDSA withholds support for international sepsis guidelines
The IDSA’s major concern with the guidelines is that they fail to recognize the “practical difficulties” in diagnosing sepsis. The authors reported that up to 40% of patients admitted to ICUs for sepsis do not have an infection
, and therefore, do not have sepsis.“
Hence, the benefits of treating patients who are infected need to be balanced against the harms of treating patients who at first appear as if they might have infections but in fact do not
,” they wrote.
The guidelines strongly recommend initiating IV antimicrobials within 1 hour of identifying suspected sepsis or septic shock. Although it is “understandable and appropriate” to immediately administer broad-spectrum antibiotics and fluids to patients with suspected septic shock, the authors noted that health care providers should take the time to gather additional data and decide whether antibiotics are necessary in patients presenting with less severe disease who may not have an infection.
Their other major points include inadequate guidance on the use of procalcitonin, especially to limit antibiotic duration. The recommendation of 7-10 days of antibiotics does not take into consideration infections for which shorter durations give superior results. The guidelines also do not address de-escalation after identifying a pathogen and its sensitivities.
I believe that injudicious antibiotic use in the ICU represents the greatest danger for antibiotic resistance. The IDSA position brings an important nuanced assessment of the sepsis controversy. I hope all students and houseofficers will read this and understand the importance of this common sense paper. Bravo IDSA!!!
As an ICU physician and one of the people who drafted the initial “Sepsis guidelines” in 1991-1992, I want to point out they were not drafted with the intent of clinical use, rather as study criteria for the evaluation of sepsis drugs, in that case Xigris (unsuccessful).
i was one of the people who said that they should not be used as clinical criteria, since the whole concept of sepsis is ill-defined and difficult to validate. This fell on deaf ears and within a short period of time I saw ER diagnoses of R/o SIRS. IT soon became a routine clinical diagnosis, even though it was not originally meant to be.
Once started there is nothing to be done. unfortunately, the concept of defining sepsis has taken hold. I wrote about it in Thorax in the mid 1990’s I believe) and I despaired of a definition, preferring to opt for teaching people what to look for and how to evaluate possible infection.
(In fact, the term “sepsis” is rather new. Throughout the first two thirds of the 20th Century the terms used were “septicemia” – presumably a positive blood culture with clinical signs of infection, or “antisepsis” – ways to sterilize an environment). Sepsis came from the Greek for “putrid” – the way many infections were diagnosed in the late 19th century. It was not a particularly sensitive or specific method but it was pretty much all they had for things like puerperal infections).
It is predictable that this approach will result in much of what the IDSA fears. But they are not without some culpability – since the ID doctors have not devoted a lot of attention to teaching non-Id doctors about the diagnosis of infection in different arenas.
What goes around comes around. AndI have no idea what to do about it.
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