Sepsis in Adults

Background

• The Third International Consensus Definition of Sepsis is life-threatening organ dysfunction caused by dysregulated host response to infection.

• Without timely treatment, sepsis may advance to septic shock, which is defined as vasodilatory hypotension below a mean arterial pressure of 65 mmHg and lactate level > 2 mmol/L (18 mg/dL) despite adequate fluid resuscitation and is associated with increased mortality (> 40%).
• Sepsis occurs when the host response to an infectious pathogen causes life-threatening organ dysfunction, as manifested by
  • An increase in Sequential Organ Failure Assessment (SOFA) score of ≥ 2, which objectively measures function in 6 different domains: pulmonary (oxygen requirements), renal (creatinine), neurologic status (Glasgow Coma Score), coagulation (platelet counts), liver function (bilirubin) and cardiovascular (systolic blood pressure).
• Septic shock, which is a subset of sepsis specifically defined by vasodilatory hypotension below a mean arterial pressure of 65 mm Hg and lactate level of > 2 mmol/L (18 mg/dL) despite adequate fluid resuscitation.
• Approximately 750,000 cases of sepsis occur annually in the United States.
• Infection with gram-positive organisms appears to be the most common cause of sepsis in the United States with sepsis due to fungal infections on the rise.

Evaluation

• Because organ dysfunction can be measured by an acute change in the total Sequential Organ Failure Assessment (SOFA) score of ≥ 2 points consequent to presumed infection, patients in whom sepsis is suspected should have measurements to allow calculation of the SOFA score, including vital signs, assessment of neurologic status, complete blood cell count, basic metabolic panel, and a hepatic function panel.
• The quick SOFA score (qSOFA), comprised of a respiratory rate of ≥ 22 per minute, altered mentation, and systolic blood pressure of ≤ 100 mm Hg was developed to rapidly screen for sepsis without requiring a wait for laboratory studies to be completed. qSOFA may be used at the bedside to identify patients with suspected infection likely to have a prolonged intensive care unit (ICU) stay or to die in the hospital.
• Any patient in whom sepsis is suspected should be evaluated to identify the source of infection, which may include cultures (of blood, urine, CSF, respiratory secretions), rapid viral antigen testing, or imaging studies.

Management

• Rapid delivery of care and frequent patient assessments (often requiring ICU admission) are critical to improving outcomes in patients with sepsis.
  • Cornerstones of treatment are:
    • early fluid and vasopressors for resuscitation when needed in patients with an elevated lactic acid, altered mental status, or poor urine output
    • early broad-spectrum antibiotics targeting likely pathogens
    • source control
  • Prompt management is key as hospital mortality increases with every 1 hour delay in providing appropriate antibiotics.