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Sepsis/Septicemia

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ICD-10	A40-A41
ICD-9	038.0-038.9 or 995.91
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Sepsis (in Greek Σήψις, putrefaction) is a serious medical condition caused by a severe infection. The more critical subsets of sepsis include severe sepsis (sepsis with acute organ dysfunction) and septic shock (sepsis with refractory arterial hypotension). If a proven source of infection is lacking but the other criteria of sepsis are met the condition typically meets the criteria for systemic inflammatory response syndrome (SIRS); the exception is the condition greater than 10% band forms (this is not a part of the SIRS definition).

Septicemia is sepsis of the bloodstream caused by bacteremia, which is the presence of bacteria in the bloodstream. The term septicemia is also used to refer to sepsis in general.

Symptoms

The systemic inflammatory response leads to widespread activation of inflammation and coagulation pathways. This may progress to dysfunction of the circulatory system and, even under optimal treatment result in the multiple organ dysfunction syndrome and eventually death.

Sepsis is common and also more dangerous in elderly, immunocompromised, and critically ill patients. It occurs in 2% of all hospitalizations and accounts for as much as 25% of intensive care unit (ICU) bed utilization. It is a major cause of death in intensive care units worldwide, with mortality rates that range from 20% for sepsis to 40% for severe sepsis to >60% for septic shock. In the United States, sepsis is the leading cause of death in non-coronary ICU patients, and the tenth most common cause of death overall according to 2000 data from the Centers for Disease Control and Prevention.^[1]

A problem in the adequate management of septic patients has been the delay in administering the right treatment after sepsis has been recognized. A large international collaboration was established to educate people about sepsis and to improve patient outcomes with sepsis, entitled the "Surviving Sepsis Campaign." The Campaign has published an evidence-based review of management strategies for severe sepsis,^[2] with the aim to publish a complete set of guidelines within 3 years.

Definition of sepsis

Sepsis can be diagnosed if there is a proven source of infection,^[3] such as a positive blood culture and two or more of the following^[4]:

• Heart rate > 90 beats per minute
• Body temperature < 36 (96.8°F) or > 38°C (100.4°F)
• Hyperventilation (high respiratory rate) > 20 breaths per minute or, on blood gas, a P_aCO₂ less than 32 mm Hg
• White blood cell count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 10⁹ or > 12 x 10⁹ cells/L), or greater than 10% band forms (immature white blood cells).

When two or more of these clinical parameters are met without confirmation of infection it is called systemic inflammatory response syndrome.

Treatment

The therapy of sepsis rests on antibiotics, surgical drainage of infected fluid collections, fluid replacement and appropriate support for organ dysfunction. This may include hemodialysis in kidney failure, mechanical ventilation in pulmonary dysfunction, transfusion of blood plasma, platelets and coagulation factors to stabilize blood coagulation, and drug and fluid therapy for circulatory failure. Ensuring adequate nutrition, if necessary by parenteral nutrition, is important during prolonged illness.

Most therapies aimed at the inflammatory process itself have failed to improve outcome. However, drotrecogin (activated protein C, one of the coagulation factors) has been shown to decrease mortality from about 31% to about 25% in severe sepsis.^[5] Low dose cortisol treatment has shown promise for septic shock patients with relative adrenal insufficiency.

Related conditions

• infection is an inflammatory response to a microorganism, or the invasion of normally sterile host tissues by the organism.
• bacteraemia is the presence of bacteria in the blood. Bacteraemia can occur in sepsis and other serious diseases such as infective endocarditis, but it may also be a harmless and transient condition.
• diffuse intravascular coagulation (DIC) can be the result of sepsis
• acute tubular necrosis ATN, can be the result of sepsis
• arrhythmia can be the result of sepsis
• ileus or ischemic colitis can be the result or cause of sepsis
• multiple organ dysfunction syndrome can be the result of sepsis
• meningitis, infection of the mesh that supports the brain, can be a complication or cause of sepsis
• osteomyelitis can be the cause or result of sepsis
• endocarditis, infection of the heart, can also be a complication or cause of sepsis
• pyaemia- causes abscesses

References

1. ^  Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003 Apr 17;348(16):1546-54. PMID 12700374 Full Text.
2. ^  Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM; Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004 Mar;32(3):858-73. Erratum in: Crit Care Med. 2004 Jun;32(6):1448. Correction of dosage error in text. Crit Care Med. 2004 Oct;32(10):2169-70. PMID 15090974.
3. ^  Sharma S, Steven M. Septic Shock. eMedicine.com, URL: http://www.emedicine.com/MED/topic2101.htm Accessed on Nov 20, 2005.
4. ^  Tslotou AG, Sakorafas GH, Anagnostopoulos G, Bramis J. Septic shock; current pathogenetic concepts from a clinical perspective. Med Sci Monit. 2005 Mar;11(3):RA76-85. PMID 15735579 Full Text.
5. ^  Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8;344(10):699-709. PMID 11236773 Full Text.

See also

• Septic shock
• Systemic inflammatory response syndrome

External links

• Surviving Sepsis Campaign
• International Sepsis Forum
• Advances in Sepsis journal

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