Why have clinical trials in sepsis failed?

• The biology of sepsis is complex and not specific to infection.
• Clinical criteria do not adequately delineate patients who will benefit from specific therapies.
• Stratification systems are needed to guide optimal treatment decisions.
• Success in developing new treatments will necessitate new collaborative research models.

The systemic inflammatory response is biologically complex, redundant, and activated by both infectious and noninfectious triggers. Its manipulation can cause both benefit and harm. More than 100 randomized clinical trials have tested the hypothesis that modulating the septic response to infection can improve survival. With one short-lived exception, none of these has resulted in new treatments. The current challenge for sepsis research lies in a failure of concept and reluctance to abandon a demonstrably ineffectual research model. Future success will necessitate large studies of clinical and biochemical epidemiology to understand the course of illness, better integration of basic and clinical science, and the creation of stratification systems to target treatment towards those who are most likely to benefit.