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  • Conceptual classification system for severe sepsis originally suggested by John Marshall
  • Arose from recognition that sepsis is a heterogeneous condition and that it may be possible to describe sepsis on the basis of four characteristics in the same way that cancer can be described on the basis of the TMN system. This will allow studies of more homogeneous populations in terms of prognosis and likelihood of response to therapy.
  • Currently more a framework for further research and rather than a system that has immediate clinical application. Much work is required to characterize those factors within each domain that affect prognosis and likelihood of response to therapy


  • P = predisposition
  • I = infection/insult
  • R = response
  • O = organ dysfunction

Factors likely to be important

NB Relevant factors will depend on the intervention being studied or considered and on being related to prognosis or response to therapy


Predisposition to respond to therapy

  • genetic
  • comorbidities
  • environmental/social eg alcohol
  • physician


Factors that may affect prognosis and likelihood of response to therapy

  • identifiable infection
  • source
  • severity
    • localized
    • disseminated (eg bacteraemia)
  • organisms
    • appropriate/inappropriate initial antimicrobial therapy


  • stratification of response based on:
    • biomarkers
    • conventional laboratory parameters eg WBC, procalcitonin, CRP, lactate

Organ dysfunction

  • number of organ dysfunctions
  • specific organ dysfunctions
  • magnitude of each organ dysfunction

©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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