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The Centers for Disease Control and Prevention has created a new website to alert infection preventionists, clinicians and the public about a deadly but poorly understood syndrome: sepsis.
The CDC’s ongoing sepsis initiatives have had some success, but there are good reasons to strive for improvement, says Clifford McDonald, MD, a medical epidemiologist at the CDC.
"We’re at the point of beginning to educate the infection control community about aspects of sepsis and bringing them into the Surviving Sepsis Campaign," he explains.
"The campaign has been out there or a while, and we want to work in this area [with the website] and see what we can do [to complement that]."
Sepsis is essentially a systematic inflammatory immune response to an infection that can quickly become life-threatening. Inflammation can lead to blood clots and leaky blood vessels, impairing blood flow and depriving organs of nutrients and oxygen, the CDC explains on the site. (http://www.cdc.gov/sepsis/) In severe cases, one or more organs fail. In addition, sepsis can cause the blood pressure to drop, affecting the heart and leading to septic shock. In this situation, organs may quickly fail and the patient has a high risk of death. Unfortunately, sepsis is very difficult to predict, diagnose, and treat.
The CDC notes that sepsis diagnoses in hospitals jumped from 621,000 in 2000 to more than one million cases in 2008. Moreover, "the number of cases of sepsis each year has been going up in the U.S," the CDC states. The CDC estimates a mortality rate of between 28% and 50%. Splitting the difference creates a mortality rate of 39%, meaning some 400,000 patients a year could be dying of sepsis.
Why is sepsis increasing? The CDC cites factors that include heightened awareness of the condition, an aging population with more chronic diseases, more invasive procedures and organ transplants, and greater use of immunosuppressive drugs and chemotherapy.
Different types of infections can lead to sepsis, including infections of the skin, lungs, urinary tract, and the abdomen (including appendicitis). Healthcare-associated infections (HAIs) cause some 30% to 50% of sepsis cases, but the issue is somewhat complicated, McDonald explains. Recent evidence suggests a more nuanced origin of the disease, as it appears it is primarily a community-onset infection that is related to previous care received in a health care setting, he adds.
"We have a better understanding now that many health care infections have onset in the community," McDonald says. "They may leave with a catheter or indwelling device and come back septic from that. We need to think more broadly because it may be that over half [of sepsis] originates in the community, but it could be resulting from very invasive outpatient work that’s being done."
It’s possible that as much as 60% of sepsis infections are related to health care, he adds. HAIs such as pneumonia and central line-associated bloodstream infections (CLABSIs) catheter-associated urinary tract infections, and surgical site infections can cause sepsis. Urinary tract infections also can lead to it, as can infections of the skin including those caused by MRSA. Pneumonia and CLABSIs are among the most likely HAIs to lead to sepsis, McDonald says. In any case, the data underscore that any infection prevented could save the life of a patient who may have gone on to develop sepsis.
While sepsis tragedies involving children and young people, such as 12-year-old Rory Staunton of Queens, NY, in 2012, make newspaper headlines, most sepsis cases are among the elderly and immunocompromised patients.
"Certainly the cases like that of a young person in the community with sepsis are very notable and tragic," McDonald says. "When you look at the whole [picture] of sepsis it will be older people and probably some with health care associated infection."
Staunton’s death followed an emergency room visit, from which he was discharged without a potentially life-saving diagnosis of sepsis. The case highlights the need for clinicians nationally to learn more about the illness.
The important point is for clinicians to identify and manage people who have reached the septic state to prevent their deaths, McDonald says. Another goal is to prevent infections that lead to sepsis, and HAIs are largely preventable, he adds.
"These patients are within our grasp," he says. "They’re interacting with the health care community, which leads to infections that are preventable."
Health care providers can recommend elderly patients receive the pneumonia and influenza vaccines, which can keep them from becoming infected with diseases that can lead to sepsis, he adds. Diabetes screening and treatment also can prevent sepsis as this population is at greater risk.
"Maybe we could identify large groups of sepsis patients by their chronic conditions," McDonald says. "Diabetes is one: what can we do with diabetes early on to prevent infection and manage those cases early?"
A key tenet of the CDC’s sepsis campaign is so-called "secondary prevention," treating sepsis once it has occurred by recognizing it early and managing it immediately to prevent death, McDonald says..
"What the CDC wants to do is bring this further to the next step," McDonald explains, noting that the current focus is on answering these questions:
• What are the infections leading to sepsis cases?
• What more can we do to focus on infections?
• Who are the people becoming infected with sepsis?
Another area under study is post-discharge sepsis. The CDC would like to learn more about sepsis cases in the one or two month post-discharge period.
"What can we do differently in discharge planning?" McDonald says.
Nevertheless, early diagnosis is still the chief concern.
"There are these diagnostic criteria called systemic inflammatory response," he says. "These are things like fever, high heart rate, rapid breathing rate, blood pressure dropping, and these things all in combination are one part of it, along with a suspicion of infection."
Diagnosing sepsis based on these criteria is challenging because these symptoms can indicate many different conditions.
"You can actually achieve some of the criteria by running up the stairs," he says. "Clinical judgment is required."
Hospital clinicians and infection preventionists should ask these questions when fever, high heart rate, and rapid breathing are present:
• Is there tenderness in the stomach area upon physical examination?
• Is there coughing with the rapid heart rate?
• Do you hear crackles in their lungs and suspect pneumonia?
• Is there a high white blood cell count?
• Is the lactic acid level elevated?
"A high level of lactic acid suggests the person is septic," McDonald says. "We need to get people to think of asking for the lactic acid level."