To the Editor:
We read the article “Identifying Novel Sepsis Subphenotypes Using Temperature Trajectories” by Bhavani and colleagues (1) with great interest. The authors identified four subphenotypes of patients with sepsis from temperature trajectories and found a significant variability in clinical outcomes and inflammatory markers. However, there are a few concerns that we believe need to be mentioned.
The authors included hospitalized patients with infection according to Rhee’s criteria and did not adhere to the current Sepsis-3 definition (2) or the previous American College of Chest Physicians/Society of Critical Care Medicine sepsis definition (3). Sepsis-3 defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” We believe that this has incurred a significant bias that may be reflected as lower in-hospital mortality rates in both the derivation and validation cohorts. The authors reported an overall in-hospital mortality of 6% in the derivation cohort and 6.1% in the validation cohort. On the other hand, a U.S. nationwide inpatient database analysis revealed that in-hospital mortality declined from 23.7% to 18.4% between 2007 and 2011 (4). In that study, the authors identified sepsis, severe sepsis, and septic shock according to ICD-9 coding. Significant heterogeneity in the mortality rate among patients with septic shock is already known. We believe that the patients included in this study had “suspected infection” rather than sepsis.
As we understand it, the authors used the quick Sequential Organ Failure Assessment (qSOFA) score as an indicator of disease severity; however, qSOFA is known to be inferior to SOFA for predicting in-hospital mortality in patients in both ICU and non-ICU settings (5). Therefore, the role of baseline disease severity as an independent predictor of mortality cannot be ruled out in four temperature trajectory groups when qSOFA is used.
Supplementary Material
Footnotes
Originally Published in Press as DOI: 10.1164/rccm.201908-1525LE on September 13, 2019
Author disclosures are available with the text of this letter at www.atsjournals.org.
References
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