We require even more inclusive studies than this one if we are to define severity. Murray and colleagues state that there was poor inter-rater reliability in judging severity. They have made this observation after having excluded from their cohort almost all patients we would normally consider at risk: diabetics, immunocompromised patients, or those they considered a priori to have a severe infection. It might be difficult to further break down grades of severity when the above groups are excluded. Given the unreliability of “severity assessment,” future studies should not exclude those traditional high-risk patients, or at least should limit exclusion criteria to enroll the most externally valid patient sample.