Editors

Veli-JukkaAnttila

Sepsis

Essentials

A severe microbe-induced systemic infection with usually, but not always, positive blood culture results
Suspect sepsis in all patients who are very unwell and manifest severe symptoms.
Patient history gives clues about the probable causative agent: first symptoms of the disease, their duration, recent interventions, underlying general diseases, alcohol use, respiratory or urinary tract symptoms, immunosuppressive medication, splenectomy, wounds, bites, dental problems, travelling, etc.
Check serum CRP without delay in patients who are not to be admitted to hospital immediately.
Consider the possibility of streptococcal and staphylococcal sepsis in patients with a skin infection.
Petechiae and extensive haematoma: meningococcus, pneumococcus or Capnocytophaga canimorsus (for example, following a dog bite Bite Wounds)
Check for nuchal rigidity, and assess the level of consciousness, to diagnose meningitis in all suspected cases of severe infection.

Symptoms and signs suggesting sepsis

Criteria of the systemic inflammatory response syndrome (SIRS) http://www.dynamed.com/condition/sepsis-in-adults#NEW_CONSENSUS_DEFINITIONS; these can be used in assessing the severity of sepsis, but the need of hospitalization cannot solely be judged on these criteria.
- Body temperature > 38°C or < 36°C
- Rapid heart rate > 90/min
- Rapid respiratory rate > 20/min or pCO₂< 4.3 kPa by spontaneous breathing
- White blood cell count > 12 × 10⁹ /l or < 4 × 10⁹ /l or > 10% immature neutrophils
General malaise
Generalized or local pain
Chills
Fatigue, weakness
Nausea
Vomiting
Skin symptoms (often petechiae, haematoma)
Low blood pressure but the patient's skin is warm ("warm hypotension")
Confusion
Unexplained worsening of an underlying illness

Investigations Serum Procalcitonin (PCT) and C-Reactive Protein (Crp) Levels as Markers of Bacterial Infection in Hospitalized Patients., Accuracy of Procalcitonin for Sepsis Diagnosis in Critically Ill Patients, Effectiveness and Safety of Procalcitonin Evaluation for Reducing Mortality in Adults with Sepsis

Clinical examination http://www.dynamed.com/condition/sepsis-in-adults#MAKING_THE_DIAGNOSIS: pulse rate, blood pressure, pulse oximetry, respiration rate, heart and lung auscultation, examination of the skin, auscultation and palpation of the abdomen, examination of the mouth and throat, palpation of lymph nodes, inspection of the anal area.
A high serum CRP is a good indicator of a septic infection provided that the symptoms have lasted for at least 12 hours, before which time CRP may be normal even in the presence of sepsis.
Leucocyte count may increase earlier than the CRP concentration (and should therefore be measured if the symptoms have been present for less than 12 hours). However, a low leucocyte count does not exclude a septic infection.
A low platelet count supports the diagnosis of sepsis or other severe infectious disease (consider the possibility of epidemic nephropathia Epidemic Nephropathy).
Blood cultures should be taken twice http://www.dynamed.com/condition/sepsis-in-adults#BLOOD_CULTURES before antibiotic treatment is instigated. In septic shock, samples are taken simultaneously from both arms. The samples need not be taken during a peak in the patient's temperature. If high temperature persists, blood cultures should be repeated during antibiotic treatment.

The most common causative agents of sepsis in a previously healthy individual

E.coli
Pneumococcus
Staphylococcus aureus
Meningococcus
Group A beta-haemolytic streptococcus
In patients with symptoms from the urinary tract, E. coli, Klebsiella species and enterococci are the most common causes of urosepsis.

Treatment Intravenous Immunoglobulin for Treating Sepsis and Septic Shock, Naloxone for Shock, Corticosteroids for Treating Sepsis, Combination of Beta Lactam and Aminoglycoside Antibiotic Therapy for Sepsis, Human Recombinant Activated Protein C for Severe Sepsis, Drotrecogin Alfa for Severe Sepsis in Adults, Hydroxyethyl Starch (Hes) Versus other Fluid Therapies: Effects on Kidney Function

Fluid therapy with an electrolyte solution http://www.dynamed.com/management/sepsis-treatment-in-adults#FLUIDCHOICE (e.g. Ringer's solution) should be started as soon as possible (before transportation to the hospital) to treat the shock http://www.dynamed.com/management/sepsis-treatment-in-adults#VOLUME_RESUSCITATION. The patient may need several litres. If hypotension cannot be corrected, catecholamines (primarily noradrenaline http://www.dynamed.com/management/sepsis-treatment-in-adults#VASOPRESSORS) with gradually increasing doses can be attempted.
If the clinical picture suggests meningococcal sepsis or if the patient's general condition is poor and transportation to an intensive care unit will take more than one hour:
- start antibiotics (e.g. penicillin G, cefuroxime or a third generation cephalosporin http://www.dynamed.com/condition/meningococcal-disease#TREATMENT_OVERVIEW_IN_ADULTS)
- consult the hospital and take blood cultures before starting antibiotics (if blood culture bottles are not available transport a syringe full of blood in a warm place, e.g. jacket pocket along with the patient). Rapid initiation of antibiotic therapy may save the patient's life.
In febrile patients with granulocytopenia (neutropenia; patients receiving cytotoxic drugs), a broad-spectrum beta-lactam, e.g. a third or fourth generation cephalosporin (e.g. ceftazidime, cefepime), piperacillin-tazobactam, imipenem-cilastatin or meropenem is always started after blood cultures have been taken http://www.dynamed.com/management/sepsis-treatment-in-adults#GENERAL_CONSIDERATIONS. The combination of ceftriaxone + an aminoglycoside (e.g. tobramycin) may be used if there no suspicion of an infection caused by Pseudomonas. A patient with neutropenia may die from sepsis in a few hours without treatment. Follow the antibiotic instructions given by your own institution.
A patient with a suspected sepsis should be treated in a hospital. If there is any doubt about safety, a physician should accompany the patient during transportation.
If blood cultures are taken on a patient treated in primary care on the ward of a community health centre (with e.g. pyelonephritis or pneumonia) and they turn out to be positive but the patient's condition is clearly improving, the treatment can be continued in primary care without the need to refer the patient to a hospital unit.

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Information

Editors

Sepsis

Essentials

Symptoms and signs suggesting sepsis

The most common causative agents of sepsis in a previously healthy individual