David Oliver: Sepsis—what’s behind the “hype”?BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6327 (Published 07 November 2019) Cite this as: BMJ 2019;367:l6327
- David Oliver, consultant in geriatrics and acute general medicine
- Follow David on Twitter: @mancunianmedic
A letter was published in the Lancet last week, entitled “Sepsis hysteria: excess hype and unrealistic expectations.”1 It triggered lively Twitter exchanges under the hashtag #sepsishysteria.2 The ensuing discussion starkly exemplified some issues doctors now face when discussing contested, emotionally charged topics on social media.
What made the Lancet letter especially interesting was that the authors were recognised experts in sepsis deterioration and scores for identifying physiological decline. Mervyn Singer has been a key player in international consensus definitions of sepsis and an advocate for improving care3; Matt Inada-Kim is a national clinical adviser on sepsis and deterioration4; and Manu Shankar-Hari is a recognised sepsis researcher.5 This made their pause for critical thought all the more noteworthy and added to the considerable interest generated.
They argued that the number of cases and deaths from sepsis may be over-reported in codes for infections or scoring systems. Many deaths from genuine sepsis, defined in the letter as “life-threatening organ dysfunction caused by a dysregulated host response to infection,”1 occur in frail older people with multimorbidity and would not have been preventable even with early and aggressive treatment. Besides, the national incentivisation of a programme to screen early for sepsis and to commence early broad spectrum antibiotics and fluid resuscitation could lead to overtreatment, overuse of antibiotics, and related harms.6
There’s also a risk that, when pushed down the sepsis line by protocols and algorithms, doctors may rely less on their diagnostic acumen to identify the more varied problems behind acute presentation. Perhaps the Surviving Sepsis campaign, as well as the national push to embed sepsis screening tools, protocols, and financial incentives for hospitals, has led to fear and anger among patients who see media stories about sepsis being missed, treatment delayed, or patients dying. Yet the evidence base behind screening tools for early detection and protocols for early intensive treatment are still limited and contested—perhaps too much so to justify the hype.
Doctors’ Twitter reactions to the letter confirmed something I and many colleagues had known for some time. Many clinicians share the same concerns about overdiagnosis, over-coding, overtreatment, and iatrogenic risk. And many of us are now concerned by the reactions of patients and their families in our daily interactions or complaints driven by concerns that “it was sepsis” and that treatment was missed or delayed.7
I’m squarely behind the original cause shared by the Sepsis Trust and Surviving Sepsis.8 We don’t want to see patients dying or being harmed by a failure to spot rapid deterioration (or risk) early enough and intervene. This undoubtedly sometimes happens.
The Lancet letter found much support from doctors on social media who were pleased to see someone raising the issue; it also generated considerable tension online. I respect the authors’ academic integrity and principles for examining the impact and unintended consequences of their work and, very publicly, pausing for thought.
But patients and public alike have seen some very high profile campaigning on sepsis, and in some cases they’ve been personally bereaved or harmed by the condition and have used their experiences to lend weight to campaigns. In view of the raised expectations and vigilance, doctors now blame too much “hype” and “hysteria.”1 No wonder the reaction from patients, families, and campaigners was so strong. Wasn’t this a condition that was too often missed, where delayed treatment led to avoidable deaths?
It would be a shame if reactions became so hostile, personal, and shouty that professionals felt unable to debate these issues on public platforms.9 But articles in medical journals now have visibility well beyond their subscribers. And the very public campaigning on sepsis was, after all, designed to bring publicity.
Competing interests: See www.bmj.com/about-bmj/freelance-contributors.
Provenance and peer review: Commissioned; not externally peer reviewed.