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We know that coding of sepsis is poor.
This absence of reliable data makes it hard to compare approaches over time and between locations.
The SoS paper basically lists a lot of codes that the authors associated with infection.
The authors identified 267 codes indicating possible infection.
There were 47475 cases with these codes as a primary diagnosis, with 3440 associated deaths.
We felt that several of these reflected conditions that were not primarily infective in nature
(or at least in which antibiotics would not be a main component of acute management)
We removed the most common of these.
11. N12.X - Tubulo-interstitial nephritis, not specified as acute or chronic
13. J69.0 - Pneumonitis due to food and vomit
54. N10.X - Acute tubulo-interstitial nephritis
62. J84.9 - Interstitial pulmonary disease, unspecified
73. N71.9 - Inflammatory disease of uterus, unspecified
86. K57.1 - Diverticular disease of small intestine without perforation or abscess
90. N48.1 - Balanoposthitis
99. N48.2 - Other inflammatory disorders of penis
130. J69.8 - Pneumonitis due to other solids and liquids
The remaining 258 codes had 45521 cases with 3163 associated deaths.
95% of cases are captured using the first 76 diagnostic codes.
We felt that many of the cases reflected infections that...
We felt that many of the cases reflected infections that are highly unlikely to progress to death
One would expect this with a condition associated with sepsis.
We ranked the remaining codings by number of deaths.
95% of deaths would be captured in just 24 diagnostic codes.
We added in a number of codes that were highly likely to represent relatively common sepsis conditions,
with mortality over 10% and more than 10 cases.
117. A49.9 - Bacterial infection, unspecified
118. A40.0 - Sepsis due to streptococcus, group A
121. A41.2 - Sepsis due to unspecified staphylococcus
131. A40.3 - Sepsis due to Streptococcus pneumoniae
116. G00.9 - Bacterial meningitis, unspecified
Altogether, these 29 codes accounted for 29424 episodes with 3026 deaths :
J22.X - Unspecified acute lower respiratory infection
J18.9 - Pneumonia, unspecified
J44.0 - COPD with acute lower respiratory infection
J18.0 - Bronchopneumonia, unspecified
J13.X - Pneumonia due to Streptococcus pneumoniae
J15.1 - Pneumonia due to Pseudomonas
J18.1 - Lobar pneumonia, unspecified
N39.0 - Urinary tract infection, site not specified
Skin, soft tissue, bone
L03.1 - Cellulitis of other parts of limb
M72.6 - Necrotizing fasciitis
A41.9 - Sepsis, unspecified
A41.5 - Sepsis due to other Gram-negative organisms
A41.8 - Other specified sepsis
A41.0 - Sepsis due to Staphylococcus aureus
A41.1 - Sepsis due to other specified staphylococcus
A40.8 - Other streptococcal sepsis
J15.0 - Pneumonia due to Klebsiella pneumoniae
A40.9 - Streptococcal sepsis, unspecified
R57.2 - Septic shock
A49.9 - Bacterial infection, unspecified
A41.2 - Sepsis due to unspecified staphylococcus
A40.0 - Sepsis due to streptococcus, group A
A40.3 - Sepsis due to Streptococcus pneumoniae
K57.2 - Diverticular disease of large intestine with perforation and abscess
A04.7 - Enterocolitis due to Clostridium difficile
K63.1 - Perforation of intestine (nontraumatic)
K65.0 - Acute peritonitis
K65.9 - Peritonitis, unspecified
K83.0 - Cholangitis
I33.0 - Acute and subacute infective endocarditis
In conclusion, we captured 96% of infection deaths using just 29 diagnostic codes.
It is thus possible to simplify the analysis of Inada Kim et al considerably,
and by so doing improve the signal to noise ratio of the analysis.
We still included some conditions that are not primarily infective (eg abdominal perforation)
However, this led us to consider that a practical definition of sepsis might be
"A diagnosis for which antibiotics would generally be seen as part of acute management"
The paper only looks at primary codes, and this might miss hospital acquired sepsis.
We agree that this is likely to increase noise, but this is an area that merits further research.
We also note that the authors state “although there are non-bacterial causes of sepsis (eg, viruses, protozoa), these are (generally) far less common and amenable to treatment”
Given that influenza is one of the commonest causes of death from infection, this is perhaps hard to justify.
This will help comparative studies of sepsis management,
and provide focus on the areas that are likely to be benefit from attention.