Intensive Care Medicine

, Volume 34, Issue 3, pp 496–504 | Cite as

Sepsis mortality prediction based on predisposition, infection and response

  • Rui P. MorenoEmail author
  • Barbara Metnitz
  • Leopold Adler
  • Anette Hoechtl
  • Peter Bauer
  • Philipp G. H. Metnitz
  • SAPS 3 Investigators



To empirically test, based on a large multicenter, multinational database, whether a modified PIRO (predisposition, insult, response, and organ dysfunction) concept could be applied to predict mortality in patients with infection and sepsis.


Substudy of a multicenter multinational cohort study (SAPS 3).


A total of 2,628 patients with signs of infection or sepsis who stayed in the ICU for > 48 h. Three boxes of variables were defined, according to the PIRO concept. Box 1 (Predisposition) contained information about the patient's condition before ICU admission. Box 2 (Injury) contained information about the infection at ICU admission. Box 3 (Response) was defined as the response to the infection, expressed as a Sequential Organ Failure Assessment score after 48 h.



Main measurements and results

Most of the infections were community acquired (59.6%); 32.5% were hospital acquired. The median age of the patients was 65 (50–75) years, and 41.1% were female. About 22% (n = 576) of the patients presented with infection only, 36.3% (n = 953) with signs of sepsis, 23.6% (n = 619) with severe sepsis, and 18.3% (n = 480) with septic shock. Hospital mortality was 40.6% overall, greater in those with septic shock (52.5%) than in those with infection (34.7%). Several factors related to predisposition, infection and response were associated with hospital mortality.


The proposed three-level system, by using objectively defined criteria for risk of mortality in sepsis, could be used by physicians to stratify patients at ICU admission or shortly thereafter, contributing to a better selection of management according to the risk of death.


Intensive care unit Severity of illness Infection Sepsis PIRO Risk adjustment 



Statistical analysis was supported by a grant from the Fund of the Austrian National Bank, Project # 10995 ONB. Our thanks go to the participants from all over the world who dedicated a significant amount of their time and effort to this project, proving that it is still possible to conduct a worldwide academic study. The complete list of participants can be found in Appendix D of the ESM.

Supplementary material

134_2007_943_MOESM1_ESM.doc (3.2 mb)
Electronic Supplementary Material (DOC 3,3M)


  1. 1.
    Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101:1644–1655PubMedCrossRefGoogle Scholar
  2. 2.
    Vincent JL (1997) Dear SIRS, I'm sorry to say that I don't like you ... Crit Care Med 25:372–374PubMedCrossRefGoogle Scholar
  3. 3.
    Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, International Sepsis Definitions Conference (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med 29:530–538PubMedGoogle Scholar
  4. 4.
    Marshall JC, Vincent JL, Fink MP, Cook DJ, Rubenfeld G, Foster D, Fisher CJ Jr, Faist E, Reinhart K (2003) Measures, markers, and mediators: Toward a staging system for clinical sepsis. A Report of the Fifth Toronto Sepsis Roundtable, Toronto, Ontario, Canada, 25–26 October, 2000. Crit Care Med 31:1560–1567PubMedCrossRefGoogle Scholar
  5. 5.
    Vincent JL, Wendon J, Groeneveld J, Marshall JC, Streat S, Carlet J (2003) The PIRO Concept: O is for organ dysfunction. Crit Care 7:260–264PubMedCrossRefGoogle Scholar
  6. 6.
    Angus DC, Burgner D, Wunderink R, Mira JP, Gerlach H, Wiedermann CJ, Vincent JL (2003) The PIRO Concept: P is for predisposition. Crit Care 7:248–251PubMedCrossRefGoogle Scholar
  7. 7.
    Gerlach H, Dhainaut JF, Harbarth S, Reinhart K, Marshall JC, Levy M (2003) The PIRO Concept: R is for response. Crit Care 7:256–259PubMedCrossRefGoogle Scholar
  8. 8.
    Vincent JL, Opal S, Torres A, Bonten M, Cohen J, Wunderink R (2003) The PIRO Concept: I is for infection. Crit Care 7:252–255PubMedCrossRefGoogle Scholar
  9. 9.
    Metnitz PG, Moreno RP, Almeida E, Jordan B, Bauer P, Campos RA, Iapichino G, Edbrooke D, Capuzzo M, Le Gall JR; SAPS 3 Investigators (2005) SAPS 3. From evaluation of the patient to evaluation of the intensive care unit. Part 1: Objectives, methods and cohort description. Intensive Care Med 31:1336–1344PubMedCrossRefGoogle Scholar
  10. 10.
    Moreno RP, Metnitz PG, Almeida E, Jordan B, Bauer P, Campos RA, Iapichino G, Edbrooke D, Capuzzo M, Le Gall JR; SAPS 3 Investigators (2005) SAPS 3. From evaluation of the patient to evaluation of the intensive care unit. Part 2: Development of a prognostic model for hospital mortality at ICU admission. Intensive Care Med 31:1345–1355PubMedCrossRefGoogle Scholar
  11. 11.
    Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 22:707–710PubMedCrossRefGoogle Scholar
  12. 12.
    Kramer MS, Feinstein AR (1981) Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther 29:111–123PubMedCrossRefGoogle Scholar
  13. 13.
    Hosmer DW, Lemeshow S (1995) Confidence interval estimates of an index of quality performance based on logistic regression estimates. Stat Med 14:2161–2172PubMedCrossRefGoogle Scholar
  14. 14.
    Lemeshow S, Hosmer DW (1982) A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol 115:92–106PubMedGoogle Scholar
  15. 15.
    Hanley J, McNeil B (1982) The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143:29–36PubMedGoogle Scholar
  16. 16.
    Alberti C, Brun-Buisson C, Burchardi H, Martin C, Goodman S, Artigas A, Sicignano A, Palazzo M, Moreno R, Boulmé R, Lepage E, Le Gall R (2002) Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study. Intensive Care Med 28:108–121PubMedCrossRefGoogle Scholar
  17. 17.
    Martin GS, Mannino DM, Eaton S, Moss M (2003) The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 348:1546–1554PubMedCrossRefGoogle Scholar
  18. 18.
    Moreno R, Afonso S, Fevereiro T (2006) Incidence of sepsis in hospitalized patients. Curr Infect Dis Rep 8:346–350PubMedCrossRefGoogle Scholar
  19. 19.
    Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM (2004) Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock. Intensive Care Med 30:536–555PubMedCrossRefGoogle Scholar
  20. 20.
    Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP (1995) The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. JAMA 273:117–123PubMedCrossRefGoogle Scholar
  21. 21.
    Alberti C, Brun-Buisson C, Goodman SV, Guidici D, Granton J, Moreno R, Smithies M, Thomas O, Artigas A, Le Gall JR, European Sepsis Group (2003) Influence of systemic inflammatory response syndrome and sepsis on outcome of critically ill infected patients. Am J Respir Crit Care Med 168:77–84PubMedCrossRefGoogle Scholar
  22. 22.
    Alberti C, Brun-Buisson C, Chevret S, Antonelli M, Goodman SV, Martin C, Moreno R, Ochagavia AR, Palazzo M, Werdan K, Le Gall JR, European Sepsis Study Group (2005) Systemic inflammatory response and progression to severe sepsis in critically ill infected patients. Am J Respir Crit Care Med 171:461–468PubMedCrossRefGoogle Scholar
  23. 23.
    Finkielman JD, Dara SI, Mohammad Z, Sujay B, Afessa B (2004) Sepsis mortality prediction based on predisposition, infection, response and organ dysfunction (PIRO) [Abstract]. Crit Care Med 32:A134CrossRefGoogle Scholar
  24. 24.
    Carlet J (2006) Prescribing indications based on successful clinical trials in sepsis: a difficult exercise. Crit Care Med 34:525–529PubMedCrossRefGoogle Scholar
  25. 25.
    Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D, Sepsis Occurrence in Acutely Ill Patients Investigators (2006) Sepsis in European intensive care units: Results of the SOAP study. Crit Care Med 34:344–353PubMedCrossRefGoogle Scholar
  26. 26.
    Flaatten H (2004) Epidemiology of sepsis in Norway in 1999. Crit Care 8:R180–R184PubMedCrossRefGoogle Scholar
  27. 27.
    Harrison DA (2006) The epidemiology of severe sepsis in England, Wales and Northern Ireland, 1996 to 2004: secondary analysis of a high quality clinical database, the ICNARC Case Mix Programme Database. Crit Care 10:doi:10.1186/cc4854Google Scholar
  28. 28.
    Friedman G, Silva E, Vincent JL (1998) Has the mortality of septic shock changed with time? Crit Care Med 26:2078–2086PubMedCrossRefGoogle Scholar
  29. 29.
    Karlsson S, Varpula M, Ruokonen E, Pettila V, Parviainen I, Ala-Kokko TI, Kolho E, Rintala EM (2007) Incidence, treatment, and outcome of severe sepsis in ICU-treated adults in Finland: the Finnsepsis study. Intensive Care Med 33:435–443PubMedCrossRefGoogle Scholar
  30. 30.
    Rangel-Frausto MS (1999) The epidemiology of bacterial sepsis. Infect Clin North Am 13:299–312CrossRefGoogle Scholar
  31. 31.
    Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Crit Care Med 29:1303–1310PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Rui P. Moreno
    • 1
    Email author
  • Barbara Metnitz
    • 2
  • Leopold Adler
    • 3
  • Anette Hoechtl
    • 3
  • Peter Bauer
    • 2
  • Philipp G. H. Metnitz
    • 3
  • SAPS 3 Investigators
    • 1
  1. 1.Unidade de Cuidados Intensivos Polivalente, Hospital de St. António dos CapuchosCentro Hospitalar de Lisboa Central E.P.E.LisbonPortugal
  2. 2.Department of Medical StatisticsUniversity of ViennaViennaAustria
  3. 3.Department of Anesthesiology and General Intensive CareUniversity Hospital of ViennaViennaAustria

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