Sepsis is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Life-threatening acute organ dysfunction caused by a dysregulated host response to infection
  • Organ dysfunction is represented by an acute increase in the Sequential Organ Failure Assessment (SOFA) score of ≥2 points from baseline.
  • Baseline SOFA score is assumed to be zero unless there is preexisting organ dysfunction.
  • SOFA variables:
    • Respiration: PaO2/FiO2 ratio
    • Central nervous system: Glasgow Coma Scale score
    • Cardiovascular: mean arterial pressure (MAP), vasopressor administration with type and rate of infusion
    • Renal: serum creatinine, urine output
    • Liver: bilirubin
    • Coagulation: platelet count
  • Quick SOFA (qSOFA) is a new bedside measure used to prompt further investigation of suspected infection or cause of organ dysfunction.
  • qSOFA variables:
    • Respiratory rate ≥22/min
    • Altered mentation
    • SBP ≤100 mm Hg
  • Septic shock: subset of sepsis, profound circulatory, cellular, and metabolic abnormalities
    • Clinically: vasopressor requirement to maintain MAP >65 mm Hg and serum lactate level >2 mmol/L (>18 mg/dL) in the absence of hypovolemia
Pediatric Considerations
  • Continuum from sepsis to multisystem organ failure (MSOF) is affected by age-specific physiologic variables in children.
  • SIRS in pediatric population requires that abnormality in temperature or WBC be present.
  • Drug metabolism is reduced in children with sepsis. Monitor drug toxicity labs to prevent adverse effects.

Geriatric Considerations
Altered mental status may be presenting sign of infection.

Epidemiology

Incidence
  • Is a leading global cause of mortality and critical illness
  • Increasing incidence with decreasing in-hospital mortality
  • 31 million cases with ~ 5 million deaths annually worldwide

Etiology and Pathophysiology

  • Complex pathophysiology
  • Multifactorial: Widespread endothelial dysfunction, complement activation, and activation of coagulation cascade leads to tissue hypoperfusion, early hemodynamic changes of sepsis resulting in organ dysfunction.
  • An imbalance between proinflammatory and anti-inflammatory mediators leads to relative immunosuppression.
  • Causative organisms (most commonly bacterial)
    • Gram-positive bacteria (most common): Staphylococcus sp., Streptococcus sp., Enterococcus sp.
    • Gram-negative: Escherichia coli, Klebsiella sp., Proteus sp., Pseudomonas sp., and anaerobic bacteria
    • Fungi: Candida sp.
    • Causative organism not identified in 1/3 of cases
    • Nosocomial infections in 50% of cases
  • Common sites of infection: upper/lower respiratory tract (most common), urinary tract, vascular and indwelling catheters, skin/soft tissue, central nervous system, gastrointestinal tract, bone, joint

Risk Factors

  • Extremes of age (very young or age >60 years)
  • Comorbidities: COPD, cirrhosis, congestive heart failure (CHF), cancer, diabetes, and renal insufficiency/failure
  • Immunosuppression, asplenia
  • Primary bacteremia
  • Complicated labor and delivery: premature labor and/or premature rupture of membranes, untreated maternal group B strep colonization
  • Nosocomial factors: surgical site infections, vascular and indwelling catheters, mechanical ventilation

General Prevention

  • Vaccination: pneumococcal vaccine in children and adults ≥65 years or immunocompromised; Haemophilus influenzae type B (infants, young children), influenza, meningococcal vaccine
  • γ-Globulin for hypo- or agammaglobulinemia
  • Regular hand washing, sterile technique for vascular and indwelling catheter placement
  • Antibiotic prophylaxis for recommended surgical procedures
  • Liberation from mechanical ventilation as soon as clinically appropriate

Commonly Associated Conditions

  • Immunologic: neutropenia, HIV, hypo- or agammaglobulinemia, complement deficiency, splenectomy, immunosuppressants (corticosteroids, chemotherapy, TNF-α antagonists)
  • Diabetes, alcoholism, malignancy, cirrhosis, burns, multiple trauma, IV drug abuse, malnutrition

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Citation

* When formatting your citation, note that all book, journal, and database titles should be italicized* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Sepsis ID - 116551 ED - Baldor,Robert A, ED - Domino,Frank J, ED - Golding,Jeremy, ED - Stephens,Mark B, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116551/all/Sepsis PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -