Representative survey of criteria used for the diagnosis of severe sepsis/septic shock among German ICU physicians: results from the German Prevalence Study

Objective

To assess the use of sepsis criteria in daily clinical practice in German ICUs.

Background

Different definitions for sepsis are used by clinicians, epidemiologists and microbiologists. In 1992, a set of definitions was agreed upon by an ACCP/SCCM panel of experts. However, a recent poll of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) showed that 87% of the responding intensivists doubt the validity of these criteria for sepsis at the bedside.

Design and setting

A prospective observational cross-sectional 1-day-prevalence study from 15 January 2003 to 14 January 2004. A representative random sample of 310 hospitals with 454 ICUs out of a total of 1380 German hospitals with 2075 ICUs was obtained, forming five strata according to hospital size: strata 1–4 comprised all non-university hospitals with <200, 201–400, 401–600, and >600 beds, respectively, and stratum 5 comprised all university hospitals. Visits by experienced ICU physicians from SepNet's 17 regional study centers were randomly distributed over a 1-year period to allow for seasonal variations. ICU directors were asked whether they used the sepsis criteria or not and marked either 'always', 'frequently', 'sometimes', 'rarely' or 'never' for their use of sepsis markers.

Results

Essential for diagnosis were: clinical criteria according to individual experience (96.5%), positive blood culture (81.5%), ACCP/SCCM Consensus Conference Criteria (56.6%). In total 37.9% stated never using Gram-stains of respiratory specimens, and in 13.2% of these ICUs the laboratory turn around for first blood culture results was >24 hours. Of ICU directors, 90.5% stated using laboratory markers for sepsis diagnosis. The absolute leucocyte count was used in 92.7% ('always'); the differential leucocyte count, however, was used only in 47.8% ('always'). C-reactive protein was the most preferred biochemical marker ('always': 90.1%), compared with procalcitonin ('always': 13.9, 'frequently': 9.5, 'sometimes': 15.2%), IL-6 (3.7, 4.2, 5.9%) and lipopolysaccharide-binding protein levels (2.4, 2.0, 3.7%).

Conclusion

The acceptance of the ACCP/SCCM criteria is low in Germany, similar to results from US and European surveys. For the diagnosis of sepsis, ICU physicians seem to rely more on their personal experience rather than on expert recommendations of standardized criteria. Procalcitonin levels are used by one-third of ICU physicians in addition to conventional laboratory markers and clinical signs of sepsis.