• Otavio T Ranzani, Elena Prina, Rosario Menéndez, Adrian Ceccato, Catia Cilloniz, Raul Méndez, Albert Gabarrus, Enric Barbeta, BassiGianluigi LiGL1 Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D'investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain., Miquel Ferrer, and Antoni Torres.
• 1 Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D'investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain.
• Am. J. Respir. Crit. Care Med. 2017 Nov 15; 196 (10): 1287-1297.

RationaleThe Sepsis-3 Task Force updated the clinical criteria for sepsis, excluding the need for systemic inflammatory response syndrome (SIRS) criteria. The clinical implications of the proposed flowchart including the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and SOFA scores are unknown.ObjectivesTo perform a clinical decision-making analysis of Sepsis-3 in patients with community-acquired pneumonia.MethodsThis was a cohort study including adult patients with community-acquired pneumonia from two Spanish university hospitals. SIRS, qSOFA, the Confusion, Respiratory Rate and Blood Pressure (CRB) score, modified SOFA (mSOFA), the Confusion, Urea, Respiratory Rate, Blood Pressure and Age (CURB-65) score, and Pneumonia Severity Index (PSI) were calculated with data from the emergency department. We used decision-curve analysis to evaluate the clinical usefulness of each score and the primary outcome was in-hospital mortality.Measurements And Main ResultsOf 6,874 patients, 442 (6.4%) died in-hospital. SIRS presented the worst discrimination, followed by qSOFA, CRB, mSOFA, CURB-65, and PSI. Overall, overestimation of in-hospital mortality and miscalibration was more evident for qSOFA and mSOFA. SIRS had lower net benefit than qSOFA and CRB, significantly increasing the risk of over-treatment and being comparable with the "treat-all" strategy. PSI had higher net benefit than mSOFA and CURB-65 for mortality, whereas mSOFA seemed more applicable when considering mortality/intensive care unit admission. Sepsis-3 flowchart resulted in better identification of patients at high risk of mortality.ConclusionsqSOFA and CRB outperformed SIRS and presented better clinical usefulness as prompt tools for patients with community-acquired pneumonia in the emergency department. Among the tools for a comprehensive patient assessment, PSI had the best decision-aid tool profile.

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