Dear Sepsis-3, we are sorry to say that we don't like you*

On February 23rd, 2016, the Journal of the American Medical Association (JAMA) published a proposal for new definitions and criteria for sepsis, which the authors called Sepsis-3.(1) At the same time, the authors named the previous sepsis definitions Sepsis-1 (from 1991)(2) and Sepsis-2 (from 2001)(3) (Table 1). The proposal was prepared by a task force appointed by the European Society of Intensive Care Medicine (ESICM) and the Society of Critical Care Medicine (SCCM), which was composed of 19 specialists in intensive care, infectious diseases, surgery and pneumology. The document was subscribed by 32 scientific societies.(1) Sepsis became defined as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.” The method used to prepare the proposal was a retrospective analysis of large hospital databases from two countries (the United States and Germany, with considerable predominance of the former) in the attempt to establish the clinical and laboratory parameters that best correlated with mortality among patients with suspected infection. To identify this cohort of patients with suspected infection in large hospital databases, the authors used non-validated criteria, including patients treated with antibiotics within 72 hours after collection of biological samples for microbiological analysis or patients subjected to sample collection up to 24 hours after the onset of antibiotic treatment. Because the definition of sepsis came to be centered on “organ dysfunction”, the task force suggested using a score of organ dysfunction/failure [i.e., the Sequential Organ Failure Assessment (SOFA)](4) as the diagnostic criterion for sepsis. According to this suggestion, a patient with an acute change in the SOFA score ≥ 2 meets the criteria for sepsis (Table 2). The task force established that the baseline SOFA score should be zero unless the patient was known to have preexisting (acute or chronic) organ dysfunction before the onset of infection. However, due to the limitations of SOFA outside the intensive care unit (ICU), the task force recommended a new score [i.e., “quick SOFA” (qSOFA)]. This instrument, which was also developed by the task force and was not validated in clinical practice, comprised three clinical parameters that were easy to assess (Table 3) and were associated with high mortality when at least two of them were simultaneously present. In contrast, SOFA includes laboratory data and therapeutic approaches that have different scores according to pre-defined thresholds. In turn, septic shock was defined as a “subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality.” António Henriques Carneiro1, Pedro Póvoa2,3, José Andrade Gomes4