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Bacterial Sepsis

Updated : January 11, 2024





Background

Bacterial sepsis is a severe and potentially life-threatening condition when the body’s response to infection becomes dysregulated, leading to systemic inflammation and organ dysfunction. Bacteria or toxins cause it in the bloodstream.

Epidemiology

Bacterial sepsis is a significant cause of morbidity and mortality worldwide. 30 million cases of sepsis are estimated globally each year, resulting in millions of deaths. The incidence of bacterial sepsis varies across different regions and healthcare settings.

The condition is more widespread in low- and middle-income countries due to limited access to healthcare, inadequate infection control measures, and a higher burden of infectious diseases.

Anatomy

Pathophysiology

The pathophysiology of bacterial sepsis is complex and involves a combination of host immune response, inflammatory mediators, endothelial dysfunction, coagulation abnormalities, and organ dysfunction.

Early recognition, prompt administration of appropriate antibiotics, and supportive care are vital in improving outcomes for patients with bacterial sepsis.

Etiology

Bacterial sepsis can affect various organ systems in the body, and the etiology of sepsis can differ depending on the specific organ system involved. Here’s an overview of organ system-specific etiologies of bacterial sepsis:

Respiratory System:

  • Pneumonia: Bacterial pneumonia caused by pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella pneumoniae, Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus – MRSA), and Legionella pneumophila can lead to sepsis.
  • Lung abscess: Infections causing lung abscesses, often associated with aspiration, can progress to sepsis.

Urinary System:

  • Urinary tract infections (UTIs): Bacteria, particularly Escherichia coli, Klebsiella pneumoniae, Enterococcus spp., and Proteus spp., can cause UTIs, and if left untreated or if the infection spreads to the bloodstream, sepsis can develop.

Gastrointestinal System:

  • Intra-abdominal infections: Infections such as appendicitis, diverticulitis, perforated bowel, or peritonitis can lead to sepsis. The causative bacteria can include Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, and other enteric bacteria.
  • Cholangitis: Bacterial infection in the bile ducts, often associated with gallstones or biliary obstruction, can lead to sepsis. Common pathogens involved include Escherichia coli, Klebsiella pneumoniae, and Enterococcus spp.

Skin and Soft Tissues:

  • Cellulitis: Bacterial skin infections like cellulitis can progress to sepsis. Common causative organisms include Streptococcus pyogenes, Staphylococcus aureus (including MRSA), and Enterococcus spp.
  • Necrotizing fasciitis: A severe and rapidly progressing soft tissue infection caused by bacteria such as Streptococcus pyogenes, Staphylococcus aureus, and Clostridium spp. can result in sepsis.

Central Nervous System:

  • Meningitis: Bacterial meningitis, caused by pathogens like Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, and Listeria monocytogenes, can lead to sepsis.

Cardiovascular System:

  • Infective endocarditis: Bacterial infection of the heart valves can cause infective endocarditis, and if left untreated, it can lead to sepsis. Common pathogens involved include Staphylococcus aureus, Streptococcus viridans, and Enterococcus spp.

Genetics

Prognostic Factors

Age: Advanced age is consistently associated with worse outcomes in sepsis. Older adults have a higher mortality risk and are more likely to experience complications.

Comorbidities: Pre-existing medical conditions, such as chronic heart, lung, kidney, or liver disease, diabetes, cancer, or immunosuppression, can adversely affect the prognosis of sepsis. These conditions often weaken the body’s ability to fight infection and increase the risk of complications.

Severity of Illness: The severity of sepsis at presentation, measured by scoring systems like (SOFA) Sequential Organ Failure Assessment score or (APACHE) II Acute Physiology and Chronic Health Evaluation score, can serve as prognostic indicators. Higher scores indicate more significant organ dysfunction and are associated with increased mortality.

Organ Dysfunction: The extent and number of organs affected by sepsis-associated dysfunction are solid prognostic factors. Multiple organ dysfunction syndrome (MODS) significantly increases the risk of mortality.

Source of Infection: The specific site or source of infection can influence prognosis. Certain sources, such as pneumonia, intra-abdominal infections, or bloodstream infections, may be associated with a higher risk of complications or treatment challenges.

Delayed Initiation of Treatment: Delayed or inadequate initiation of appropriate antibiotic therapy and supportive care can negatively impact outcomes in sepsis. Timely recognition and prompt treatment are essential to improve prognosis.

Microbial Factors: The infecting microorganism and its virulence or resistance patterns can influence prognosis. For example, infections caused by drug-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA) or multidrug-resistant Gram-negative bacteria, may be associated with worse outcomes.

Biomarkers: Certain biomarkers, such as lactate levels, C-reactive protein (CRP), procalcitonin (PCT), or markers of coagulation abnormalities (e.g., disseminated intravascular coagulation – DIC), can provide valuable prognostic information in sepsis.

Immune Response: Individual variations in the immune response and genetic factors can impact the prognosis of sepsis. Genetic polymorphisms related to inflammatory and immune responses have been associated with variations in sepsis outcomes.

Clinical History

CLINICAL HISTORY 

Non-specific signs & symptoms

  • Fever with/without chills
  • Impaired mental condition
  • Increased breathing
  • Warm/cold skin
  • Hypotension

Systemic signs & symptoms 

  • Respiratory infection
  • Gastrointestinal infection
  • Genitourinary infection
  • Surgical wound infection

Age Group:  

  • Neonates
  • Infants
  • Children
  • Adolescents
  • Adults
  • Elderly

 

Physical Examination

PHYSICAL EXAMINATION 

During the physical examination of a patient suspected of having bacterial sepsis, healthcare providers will assess various signs and symptoms that may indicate the presence of infection and sepsis. The examination will thoroughly assess the patient’s vital signs, general appearance, and specific physical findings. The components of the physical examination of bacterial sepsis include:

  • Vital Signs: The patient’s vital signs will be closely monitored, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.
  • General Appearance: The patient’s overall appearance is observed by signs of distress, such as restlessness, agitation, or lethargy, may be observed.
  • Skin Examination: The skin will be inspected for signs of infection and perfusion. Findings such as warmth, redness, swelling (edema), or purulent discharge may indicate a localized infection.
  • Respiratory Examination: The respiratory system will be evaluated for signs of respiratory distress, such as increased respiratory rate, use of accessory muscles, and labored breathing. Lung auscultation may reveal abnormal breath sounds, such as crackles or decreased breath sounds, indicating possible pneumonia or acute respiratory distress syndrome (ARDS).
  • Cardiovascular Examination: The cardiovascular system will be assessed for signs of circulatory compromise. The heart rate and rhythm will be evaluated, particularly tachycardia. Blood pressure may be low, and orthostatic hypotension be noted. The peripheral pulses and capillary refill time will be checked to assess peripheral perfusion.
  • Abdominal Examination: The abdomen will be examined for tenderness, distension, or signs of peritonitis. These findings may suggest an intra-abdominal infection as a potential source of sepsis. The presence of an enlarged liver or spleen may indicate systemic involvement.
  • Neurological Examination: The neurological status will be assessed, including cranial nerve function, motor strength, sensory examination, and reflexes. Changes in neurological function, such as confusion, delirium, or focal neurological deficits, may indicate severe sepsis affecting the central nervous system.
  • Other System-Specific Examination: Additional system-specific examinations may be performed depending on the patient’s symptoms and the suspected source of infection. For example, an examination of the genitourinary system, musculoskeletal system, or central venous access sites may be conducted if there are indications of infection in those areas.

Age group

Associated comorbidity

Associated Comorbidity or Activity: 

  • Immunosuppression
  • Diabetes
  • Chronic kidney failure
  • Chronic lung disease
  • Liver disease
  • Cardiovascular disease
  • Surgical procedures
  • Substance abuse
  • Advanced age

Associated activity

Acuity of presentation

Acuity of Presentation: 

In some cases, bacterial sepsis can have a sudden and acute onset. The patient may rapidly deteriorate within hours or even minutes. This is common in severe infections, such as meningococcal sepsis or pneumonia. The patient may present with a sudden high fever, chills, altered mental status, hypotension, rapid breathing, and signs of organ dysfunction. This rapid onset requires immediate medical attention.

Subacute Presentation:

Bacterial sepsis can also have a subacute presentation, with symptoms that develop over days. The patient may initially experience nonspecific symptoms such as fever, fatigue, generalized weakness, and malaise. As the infection progresses, they may develop more specific signs of sepsis, including increased heart rate, respiratory distress, and organ dysfunction. This subacute presentation can be seen in intra-abdominal or urinary tract infections that gradually worsen.

Differential Diagnoses

DIFFERENTIAL DIAGNOSIS

Endocrine 

  • Thyrotoxicosis
  • Adrenal insufficiency

Toxidromes 

  • Salicylate toxicity
  • Malignant hyperthermia
  • Neuroleptic malignant
  • Anticholinergic toxicity
  • syndrome
  • Heat stroke

Severe Inflammatory States 

  • Major trauma
  • Burns
  • Pancreatitis
  • Anaphylaxis

Shock Types 

  • Cardiogenic shock
  • Hypovolemic shock
  • Distributive shock
  • Obstructive shock

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

  • Early Recognition and Diagnosis: Early recognition of sepsis is essential. Healthcare providers should be vigilant for signs and symptoms, such as fever, elevated heart rate, increased respiratory rate, altered mental status, and signs of organ dysfunction.
  • Stabilization and Supportive Care: Immediate resuscitation includes providing oxygen and intravenous fluids to maintain adequate tissue perfusion.
  • Source Control: Identification and control of the source of infection are critical. This may involve surgical procedures to drain or remove abscesses, infected tissues, or devices.
  • Empirical Antibiotic Therapy: Broad-spectrum antibiotics are initiated as soon as sepsis is suspected. The choice of antibiotics is based on the likely source of infection and local antibiotic resistance patterns.
  • Monitoring: Continuous monitoring of vital signs, laboratory values, and organ function is essential to assess the patient’s response to treatment and guide further interventions.
  • Prevention and Surveillance: Infection control measures should be in place to prevent healthcare-associated infections.
  • Regular surveillance and audits can help identify and address issues that contribute to sepsis.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Use of Non-pharmacological approach for Bacterial Sepsis

  • Infection Control Measures: Implement strict infection control measures to prevent the transmission of bacteria. This includes proper hand hygiene practices for healthcare providers and visitors, personal protective equipment (such as gloves, gowns, and masks), and adherence to isolation precautions when necessary.
  • Keep Isolation Rooms: Place patients with bacterial sepsis in isolation rooms, especially with multidrug-resistant organisms or contagious infections. Isolation rooms help contain pathogens, limit exposure to susceptible individuals, and reduce the risk of cross-infection.
  • Cleanliness and Disinfection: Maintain a clean environment by regularly cleaning and disinfecting surfaces, equipment, and patient care areas. Use appropriate disinfectants effective against the pathogens of concern.
  • Ventilation: Ensure adequate ventilation in patient care areas to improve air circulation and reduce the concentration of airborne pathogens. Proper ventilation systems help minimize the risk of airborne transmission of bacteria.
  • Hand Hygiene Facilities: Provide accessible hand hygiene facilities throughout the healthcare facility, including sinks with soap and water or alcohol-based hand sanitizers. Promote and educate healthcare workers, patients, and visitors about the importance of proper hand hygiene.
  • Avoidance of Crowding: Limit the number of visitors and ensure appropriate spacing between patients to prevent overcrowding. This helps reduce the potential for transmission of pathogens and promotes a more controlled and safer environment.
  • Prevention of Healthcare-Associated Infections: Implement strategies to prevent healthcare-associated infections, such as catheter-associated urinary tract infections (CAUTIs) or ventilator-associated pneumonia (VAP). This may involve proper insertion and maintenance of invasive devices, regular monitoring, and adherence to evidence-based guidelines.
  • Adequate Staffing: Ensure adequate staffing levels to provide proper care, monitor patients closely, and promptly address any concerns related to infection control. Sufficient staffing helps maintain a clean and safe environment and enables timely interventions and surveillance.
  • Education and Training: Provide ongoing education and training to healthcare providers regarding infection control practices, early recognition of sepsis, and appropriate management strategies. This helps ensure a consistent and knowledgeable approach to preventing and managing bacterial sepsis.

Antimicrobial Stewardship: Implement antimicrobial stewardship programs to promote the judicious use of antibiotics, prevent the emergence of antimicrobial resistance, and optimize patient outcomes. This includes appropriate antibiotic selection, dose optimization, and duration of therapy.

Use of various antibiotics

Antibiotics are typically administered as soon as bacterial sepsis is suspected to cover a wide range of potential pathogens. These antibiotics are chosen based on the likely source of infection and local antibiotic resistance patterns.

  • Imipenem: Imipenem is a broad-spectrum carbapenem antibiotic that is effective against a wide range of bacteria, including many gram-positive and gram-negative pathogens.

It is often used empirically in sepsis treatment when the causative organism is unknown, and there is a need for broad coverage.

  • Clindamycin: Clindamycin is an antibiotic that primarily covers gram-positive bacteria, including streptococci, staphylococci, and anaerobic pathogens.

It is often used to treat skin and soft tissue infections associated with sepsis or to provide coverage against anaerobic organisms.

  • Metronidazole: Metronidazole is an antibiotic primarily used to target anaerobic bacteria and protozoa.

It is commonly used in the management of intra-abdominal and pelvic infections, such as intra-abdominal abscesses, where anaerobes may be involved.

  • Cefepime: Cefepime is a broad-spectrum cephalosporin antibiotic effective against both gram-positive and gram-negative bacteria.

It is often used empirically for a wide range of infections, including sepsis, particularly in critically ill patients.

  • Levofloxacin: Levofloxacin is a fluoroquinolone antibiotic that covers a broad spectrum of gram-negative and some gram-positive bacteria.

It may be used in the treatment of sepsis, especially in cases where respiratory or urinary tract infections are suspected.

  • Vancomycin: Vancomycin is a glycopeptide antibiotic that is active against gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA).

It is commonly used in cases of suspected or confirmed gram-positive bacterial infections, such as skin and soft tissue infections, pneumonia, and sepsis.

Use of Intervention with a procedure in treating Bacterial Sepsis

  • Source Control Procedures: Source control refers to procedures aimed at removing or controlling the source of infection. These procedures may include:
  • Surgical Drainage: Surgical drainage may be performed in cases of localized infections, such as abscesses or infected fluid collections. This involves an incision to access the infected area, removing pus or infected material, and establishing appropriate drainage. The procedure may be guided by imaging techniques like computed tomography (CT) or ultrasound to accurately locate the source of infection.
  • Debridement: In certain cases of necrotizing soft tissue infections, debridement may be necessary. This involves surgically removing dead or infected tissue to prevent further spread of infection and promote healing.
  • Source Control in Specific Infections: In some instances, specific procedures may be required to address the source of infection. For example, drainage or removal of infected prosthetic devices (such as infected intravenous catheters or joint prostheses) may be necessary.
  • Vascular Access Procedures: In patients with severe sepsis or septic shock, vascular access procedures may be performed to facilitate fluid resuscitation and administration of medications.
  • Central Venous Catheter Placement: Central venous catheters, such as central venous lines or peripherally inserted central catheters (PICC), may be inserted to provide central access for administering intravenous fluids, medications, and monitoring.
  • Arterial Catheter Placement: Arterial catheters may be inserted to continuously monitor blood pressure and facilitate frequent arterial blood gas sampling to assess oxygenation and acid-base status.
  • Hemodynamic Monitoring Procedures: Continuous hemodynamic monitoring may be necessary to guide fluid resuscitation and optimize patient management.

Use of phases in managing Bacterial Sepsis

  • Recognition and Early Intervention: This phase begins with the recognition of sepsis, which involves identifying signs and symptoms such as fever, elevated heart rate, increased respiratory rate, and altered mental status.
  • Stabilization and Support: After the initial resuscitation, the focus shifts to stabilizing the patient’s vital signs and addressing any organ dysfunction.
  • Source control measures, such as surgical drainage of abscesses or removal of infected devices, are initiated.
  • Antibiotic Therapy: Broad-spectrum antibiotics are administered to target the likely causative pathogens. Antibiotic therapy is adjusted based on culture and sensitivity results once they become available.
  • Hemodynamic Support: Patients with sepsis often develop low blood pressure and require vasopressor medications to maintain adequate perfusion to vital organs.
  • Supportive Care Phase: Patients may require mechanical ventilation for respiratory support. Renal replacement therapy (dialysis) may be necessary for patients with kidney dysfunction.
  • Monitoring Assessment: Continuous monitoring of vital signs, laboratory values, and organ function is crucial to assess the patient’s response to treatment and guide further interventions.

The Sequential Organ Failure Assessment (SOFA) score and other tools are used to assess organ dysfunction and predict patient outcomes.

  • Rehabilitation and Recovery Phase: After the acute phase of sepsis, patients often require rehabilitation to address physical and functional impairments that result from the illness.
  • Rehabilitation may include physical therapy, occupational therapy, and psychological support.
  • Prevention and Surveillance: Infection control measures are crucial to prevent healthcare-associated infections during the patient’s stay in the hospital.
  • Regular surveillance and audits can help identify and address issues that contribute to sepsis.

Medication

 

cefotaxime

1 g IM or IV given every 12hrs for mild conditions
1-2 g IM or IV every 8hrs moderate to severe infections
2 g IV every 6-8hrs high dosing for infections
2 g IV every 4hrs for life-threatening infections
12 g is the maximum dose required per day
Cesarean Section:
1 g IV given as soon as the umbilical cord clamped
additional 1 g IM or IV given at six and 12hrs after the initial dose



norepinephrine 

Intravenous infusion rate of 0.01-3.3 mcg/kg/min



ulinastatin 

200000 IU twice a day for 5 days



ulinastatin 

200000 IU twice a day for 5 days



 

cefotaxime

0-1 week: 50 mg per kg IV every 12hrs
1-4 weeks: 50 mg per kg IV every 8hrs
Age: 1 month-12 years
for weight: <50 kg
50-180 mg per kg IM or IV has given per day divided into 4 to 6 equal doses
for weight: >50 kg
1 g IM or IV given every 12hrs for mild conditions
1-2 g IM or IV every 8hrs moderate to severe infections
2 g IV every 6-8hrs high dosing for infections
2 g IV every 4hrs for life-threatening infections
12 g is the maximum dose required per day
Age: >12 years
1 g IM or IV given every 12hrs for mild conditions
1-2 g IM or IV every 8hrs moderate to severe infections
2 g IV every 6-8hrs high dosing for infections
2 g IV every 4hrs for life-threatening infections
12 g is the maximum dose required per day
Higher doses are given to treat more severe or serious infections



 

Media Gallary

Bacterial Sepsis

Updated : January 11, 2024




Bacterial sepsis is a severe and potentially life-threatening condition when the body’s response to infection becomes dysregulated, leading to systemic inflammation and organ dysfunction. Bacteria or toxins cause it in the bloodstream.

Bacterial sepsis is a significant cause of morbidity and mortality worldwide. 30 million cases of sepsis are estimated globally each year, resulting in millions of deaths. The incidence of bacterial sepsis varies across different regions and healthcare settings.

The condition is more widespread in low- and middle-income countries due to limited access to healthcare, inadequate infection control measures, and a higher burden of infectious diseases.

The pathophysiology of bacterial sepsis is complex and involves a combination of host immune response, inflammatory mediators, endothelial dysfunction, coagulation abnormalities, and organ dysfunction.

Early recognition, prompt administration of appropriate antibiotics, and supportive care are vital in improving outcomes for patients with bacterial sepsis.

Bacterial sepsis can affect various organ systems in the body, and the etiology of sepsis can differ depending on the specific organ system involved. Here’s an overview of organ system-specific etiologies of bacterial sepsis:

Respiratory System:

  • Pneumonia: Bacterial pneumonia caused by pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella pneumoniae, Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus – MRSA), and Legionella pneumophila can lead to sepsis.
  • Lung abscess: Infections causing lung abscesses, often associated with aspiration, can progress to sepsis.

Urinary System:

  • Urinary tract infections (UTIs): Bacteria, particularly Escherichia coli, Klebsiella pneumoniae, Enterococcus spp., and Proteus spp., can cause UTIs, and if left untreated or if the infection spreads to the bloodstream, sepsis can develop.

Gastrointestinal System:

  • Intra-abdominal infections: Infections such as appendicitis, diverticulitis, perforated bowel, or peritonitis can lead to sepsis. The causative bacteria can include Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, and other enteric bacteria.
  • Cholangitis: Bacterial infection in the bile ducts, often associated with gallstones or biliary obstruction, can lead to sepsis. Common pathogens involved include Escherichia coli, Klebsiella pneumoniae, and Enterococcus spp.

Skin and Soft Tissues:

  • Cellulitis: Bacterial skin infections like cellulitis can progress to sepsis. Common causative organisms include Streptococcus pyogenes, Staphylococcus aureus (including MRSA), and Enterococcus spp.
  • Necrotizing fasciitis: A severe and rapidly progressing soft tissue infection caused by bacteria such as Streptococcus pyogenes, Staphylococcus aureus, and Clostridium spp. can result in sepsis.

Central Nervous System:

  • Meningitis: Bacterial meningitis, caused by pathogens like Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, and Listeria monocytogenes, can lead to sepsis.

Cardiovascular System:

  • Infective endocarditis: Bacterial infection of the heart valves can cause infective endocarditis, and if left untreated, it can lead to sepsis. Common pathogens involved include Staphylococcus aureus, Streptococcus viridans, and Enterococcus spp.

Age: Advanced age is consistently associated with worse outcomes in sepsis. Older adults have a higher mortality risk and are more likely to experience complications.

Comorbidities: Pre-existing medical conditions, such as chronic heart, lung, kidney, or liver disease, diabetes, cancer, or immunosuppression, can adversely affect the prognosis of sepsis. These conditions often weaken the body’s ability to fight infection and increase the risk of complications.

Severity of Illness: The severity of sepsis at presentation, measured by scoring systems like (SOFA) Sequential Organ Failure Assessment score or (APACHE) II Acute Physiology and Chronic Health Evaluation score, can serve as prognostic indicators. Higher scores indicate more significant organ dysfunction and are associated with increased mortality.

Organ Dysfunction: The extent and number of organs affected by sepsis-associated dysfunction are solid prognostic factors. Multiple organ dysfunction syndrome (MODS) significantly increases the risk of mortality.

Source of Infection: The specific site or source of infection can influence prognosis. Certain sources, such as pneumonia, intra-abdominal infections, or bloodstream infections, may be associated with a higher risk of complications or treatment challenges.

Delayed Initiation of Treatment: Delayed or inadequate initiation of appropriate antibiotic therapy and supportive care can negatively impact outcomes in sepsis. Timely recognition and prompt treatment are essential to improve prognosis.

Microbial Factors: The infecting microorganism and its virulence or resistance patterns can influence prognosis. For example, infections caused by drug-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA) or multidrug-resistant Gram-negative bacteria, may be associated with worse outcomes.

Biomarkers: Certain biomarkers, such as lactate levels, C-reactive protein (CRP), procalcitonin (PCT), or markers of coagulation abnormalities (e.g., disseminated intravascular coagulation – DIC), can provide valuable prognostic information in sepsis.

Immune Response: Individual variations in the immune response and genetic factors can impact the prognosis of sepsis. Genetic polymorphisms related to inflammatory and immune responses have been associated with variations in sepsis outcomes.

CLINICAL HISTORY 

Non-specific signs & symptoms

  • Fever with/without chills
  • Impaired mental condition
  • Increased breathing
  • Warm/cold skin
  • Hypotension

Systemic signs & symptoms 

  • Respiratory infection
  • Gastrointestinal infection
  • Genitourinary infection
  • Surgical wound infection

Age Group:  

  • Neonates
  • Infants
  • Children
  • Adolescents
  • Adults
  • Elderly

 

PHYSICAL EXAMINATION 

During the physical examination of a patient suspected of having bacterial sepsis, healthcare providers will assess various signs and symptoms that may indicate the presence of infection and sepsis. The examination will thoroughly assess the patient’s vital signs, general appearance, and specific physical findings. The components of the physical examination of bacterial sepsis include:

  • Vital Signs: The patient’s vital signs will be closely monitored, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.
  • General Appearance: The patient’s overall appearance is observed by signs of distress, such as restlessness, agitation, or lethargy, may be observed.
  • Skin Examination: The skin will be inspected for signs of infection and perfusion. Findings such as warmth, redness, swelling (edema), or purulent discharge may indicate a localized infection.
  • Respiratory Examination: The respiratory system will be evaluated for signs of respiratory distress, such as increased respiratory rate, use of accessory muscles, and labored breathing. Lung auscultation may reveal abnormal breath sounds, such as crackles or decreased breath sounds, indicating possible pneumonia or acute respiratory distress syndrome (ARDS).
  • Cardiovascular Examination: The cardiovascular system will be assessed for signs of circulatory compromise. The heart rate and rhythm will be evaluated, particularly tachycardia. Blood pressure may be low, and orthostatic hypotension be noted. The peripheral pulses and capillary refill time will be checked to assess peripheral perfusion.
  • Abdominal Examination: The abdomen will be examined for tenderness, distension, or signs of peritonitis. These findings may suggest an intra-abdominal infection as a potential source of sepsis. The presence of an enlarged liver or spleen may indicate systemic involvement.
  • Neurological Examination: The neurological status will be assessed, including cranial nerve function, motor strength, sensory examination, and reflexes. Changes in neurological function, such as confusion, delirium, or focal neurological deficits, may indicate severe sepsis affecting the central nervous system.
  • Other System-Specific Examination: Additional system-specific examinations may be performed depending on the patient’s symptoms and the suspected source of infection. For example, an examination of the genitourinary system, musculoskeletal system, or central venous access sites may be conducted if there are indications of infection in those areas.

Associated Comorbidity or Activity: 

  • Immunosuppression
  • Diabetes
  • Chronic kidney failure
  • Chronic lung disease
  • Liver disease
  • Cardiovascular disease
  • Surgical procedures
  • Substance abuse
  • Advanced age

Acuity of Presentation: 

In some cases, bacterial sepsis can have a sudden and acute onset. The patient may rapidly deteriorate within hours or even minutes. This is common in severe infections, such as meningococcal sepsis or pneumonia. The patient may present with a sudden high fever, chills, altered mental status, hypotension, rapid breathing, and signs of organ dysfunction. This rapid onset requires immediate medical attention.

Subacute Presentation:

Bacterial sepsis can also have a subacute presentation, with symptoms that develop over days. The patient may initially experience nonspecific symptoms such as fever, fatigue, generalized weakness, and malaise. As the infection progresses, they may develop more specific signs of sepsis, including increased heart rate, respiratory distress, and organ dysfunction. This subacute presentation can be seen in intra-abdominal or urinary tract infections that gradually worsen.

DIFFERENTIAL DIAGNOSIS

Endocrine 

  • Thyrotoxicosis
  • Adrenal insufficiency

Toxidromes 

  • Salicylate toxicity
  • Malignant hyperthermia
  • Neuroleptic malignant
  • Anticholinergic toxicity
  • syndrome
  • Heat stroke

Severe Inflammatory States 

  • Major trauma
  • Burns
  • Pancreatitis
  • Anaphylaxis

Shock Types 

  • Cardiogenic shock
  • Hypovolemic shock
  • Distributive shock
  • Obstructive shock
  • Early Recognition and Diagnosis: Early recognition of sepsis is essential. Healthcare providers should be vigilant for signs and symptoms, such as fever, elevated heart rate, increased respiratory rate, altered mental status, and signs of organ dysfunction.
  • Stabilization and Supportive Care: Immediate resuscitation includes providing oxygen and intravenous fluids to maintain adequate tissue perfusion.
  • Source Control: Identification and control of the source of infection are critical. This may involve surgical procedures to drain or remove abscesses, infected tissues, or devices.
  • Empirical Antibiotic Therapy: Broad-spectrum antibiotics are initiated as soon as sepsis is suspected. The choice of antibiotics is based on the likely source of infection and local antibiotic resistance patterns.
  • Monitoring: Continuous monitoring of vital signs, laboratory values, and organ function is essential to assess the patient’s response to treatment and guide further interventions.
  • Prevention and Surveillance: Infection control measures should be in place to prevent healthcare-associated infections.
  • Regular surveillance and audits can help identify and address issues that contribute to sepsis.

  • Infection Control Measures: Implement strict infection control measures to prevent the transmission of bacteria. This includes proper hand hygiene practices for healthcare providers and visitors, personal protective equipment (such as gloves, gowns, and masks), and adherence to isolation precautions when necessary.
  • Keep Isolation Rooms: Place patients with bacterial sepsis in isolation rooms, especially with multidrug-resistant organisms or contagious infections. Isolation rooms help contain pathogens, limit exposure to susceptible individuals, and reduce the risk of cross-infection.
  • Cleanliness and Disinfection: Maintain a clean environment by regularly cleaning and disinfecting surfaces, equipment, and patient care areas. Use appropriate disinfectants effective against the pathogens of concern.
  • Ventilation: Ensure adequate ventilation in patient care areas to improve air circulation and reduce the concentration of airborne pathogens. Proper ventilation systems help minimize the risk of airborne transmission of bacteria.
  • Hand Hygiene Facilities: Provide accessible hand hygiene facilities throughout the healthcare facility, including sinks with soap and water or alcohol-based hand sanitizers. Promote and educate healthcare workers, patients, and visitors about the importance of proper hand hygiene.
  • Avoidance of Crowding: Limit the number of visitors and ensure appropriate spacing between patients to prevent overcrowding. This helps reduce the potential for transmission of pathogens and promotes a more controlled and safer environment.
  • Prevention of Healthcare-Associated Infections: Implement strategies to prevent healthcare-associated infections, such as catheter-associated urinary tract infections (CAUTIs) or ventilator-associated pneumonia (VAP). This may involve proper insertion and maintenance of invasive devices, regular monitoring, and adherence to evidence-based guidelines.
  • Adequate Staffing: Ensure adequate staffing levels to provide proper care, monitor patients closely, and promptly address any concerns related to infection control. Sufficient staffing helps maintain a clean and safe environment and enables timely interventions and surveillance.
  • Education and Training: Provide ongoing education and training to healthcare providers regarding infection control practices, early recognition of sepsis, and appropriate management strategies. This helps ensure a consistent and knowledgeable approach to preventing and managing bacterial sepsis.

Antimicrobial Stewardship: Implement antimicrobial stewardship programs to promote the judicious use of antibiotics, prevent the emergence of antimicrobial resistance, and optimize patient outcomes. This includes appropriate antibiotic selection, dose optimization, and duration of therapy.

Antibiotics are typically administered as soon as bacterial sepsis is suspected to cover a wide range of potential pathogens. These antibiotics are chosen based on the likely source of infection and local antibiotic resistance patterns.

  • Imipenem: Imipenem is a broad-spectrum carbapenem antibiotic that is effective against a wide range of bacteria, including many gram-positive and gram-negative pathogens.

It is often used empirically in sepsis treatment when the causative organism is unknown, and there is a need for broad coverage.

  • Clindamycin: Clindamycin is an antibiotic that primarily covers gram-positive bacteria, including streptococci, staphylococci, and anaerobic pathogens.

It is often used to treat skin and soft tissue infections associated with sepsis or to provide coverage against anaerobic organisms.

  • Metronidazole: Metronidazole is an antibiotic primarily used to target anaerobic bacteria and protozoa.

It is commonly used in the management of intra-abdominal and pelvic infections, such as intra-abdominal abscesses, where anaerobes may be involved.

  • Cefepime: Cefepime is a broad-spectrum cephalosporin antibiotic effective against both gram-positive and gram-negative bacteria.

It is often used empirically for a wide range of infections, including sepsis, particularly in critically ill patients.

  • Levofloxacin: Levofloxacin is a fluoroquinolone antibiotic that covers a broad spectrum of gram-negative and some gram-positive bacteria.

It may be used in the treatment of sepsis, especially in cases where respiratory or urinary tract infections are suspected.

  • Vancomycin: Vancomycin is a glycopeptide antibiotic that is active against gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA).

It is commonly used in cases of suspected or confirmed gram-positive bacterial infections, such as skin and soft tissue infections, pneumonia, and sepsis.

  • Source Control Procedures: Source control refers to procedures aimed at removing or controlling the source of infection. These procedures may include:
  • Surgical Drainage: Surgical drainage may be performed in cases of localized infections, such as abscesses or infected fluid collections. This involves an incision to access the infected area, removing pus or infected material, and establishing appropriate drainage. The procedure may be guided by imaging techniques like computed tomography (CT) or ultrasound to accurately locate the source of infection.
  • Debridement: In certain cases of necrotizing soft tissue infections, debridement may be necessary. This involves surgically removing dead or infected tissue to prevent further spread of infection and promote healing.
  • Source Control in Specific Infections: In some instances, specific procedures may be required to address the source of infection. For example, drainage or removal of infected prosthetic devices (such as infected intravenous catheters or joint prostheses) may be necessary.
  • Vascular Access Procedures: In patients with severe sepsis or septic shock, vascular access procedures may be performed to facilitate fluid resuscitation and administration of medications.
  • Central Venous Catheter Placement: Central venous catheters, such as central venous lines or peripherally inserted central catheters (PICC), may be inserted to provide central access for administering intravenous fluids, medications, and monitoring.
  • Arterial Catheter Placement: Arterial catheters may be inserted to continuously monitor blood pressure and facilitate frequent arterial blood gas sampling to assess oxygenation and acid-base status.
  • Hemodynamic Monitoring Procedures: Continuous hemodynamic monitoring may be necessary to guide fluid resuscitation and optimize patient management.

  • Recognition and Early Intervention: This phase begins with the recognition of sepsis, which involves identifying signs and symptoms such as fever, elevated heart rate, increased respiratory rate, and altered mental status.
  • Stabilization and Support: After the initial resuscitation, the focus shifts to stabilizing the patient’s vital signs and addressing any organ dysfunction.
  • Source control measures, such as surgical drainage of abscesses or removal of infected devices, are initiated.
  • Antibiotic Therapy: Broad-spectrum antibiotics are administered to target the likely causative pathogens. Antibiotic therapy is adjusted based on culture and sensitivity results once they become available.
  • Hemodynamic Support: Patients with sepsis often develop low blood pressure and require vasopressor medications to maintain adequate perfusion to vital organs.
  • Supportive Care Phase: Patients may require mechanical ventilation for respiratory support. Renal replacement therapy (dialysis) may be necessary for patients with kidney dysfunction.
  • Monitoring Assessment: Continuous monitoring of vital signs, laboratory values, and organ function is crucial to assess the patient’s response to treatment and guide further interventions.

The Sequential Organ Failure Assessment (SOFA) score and other tools are used to assess organ dysfunction and predict patient outcomes.

  • Rehabilitation and Recovery Phase: After the acute phase of sepsis, patients often require rehabilitation to address physical and functional impairments that result from the illness.
  • Rehabilitation may include physical therapy, occupational therapy, and psychological support.
  • Prevention and Surveillance: Infection control measures are crucial to prevent healthcare-associated infections during the patient’s stay in the hospital.
  • Regular surveillance and audits can help identify and address issues that contribute to sepsis.

cefotaxime

1 g IM or IV given every 12hrs for mild conditions
1-2 g IM or IV every 8hrs moderate to severe infections
2 g IV every 6-8hrs high dosing for infections
2 g IV every 4hrs for life-threatening infections
12 g is the maximum dose required per day
Cesarean Section:
1 g IV given as soon as the umbilical cord clamped
additional 1 g IM or IV given at six and 12hrs after the initial dose



norepinephrine 

Intravenous infusion rate of 0.01-3.3 mcg/kg/min



ulinastatin 

200000 IU twice a day for 5 days



ulinastatin 

200000 IU twice a day for 5 days



cefotaxime

0-1 week: 50 mg per kg IV every 12hrs
1-4 weeks: 50 mg per kg IV every 8hrs
Age: 1 month-12 years
for weight: <50 kg
50-180 mg per kg IM or IV has given per day divided into 4 to 6 equal doses
for weight: >50 kg
1 g IM or IV given every 12hrs for mild conditions
1-2 g IM or IV every 8hrs moderate to severe infections
2 g IV every 6-8hrs high dosing for infections
2 g IV every 4hrs for life-threatening infections
12 g is the maximum dose required per day
Age: >12 years
1 g IM or IV given every 12hrs for mild conditions
1-2 g IM or IV every 8hrs moderate to severe infections
2 g IV every 6-8hrs high dosing for infections
2 g IV every 4hrs for life-threatening infections
12 g is the maximum dose required per day
Higher doses are given to treat more severe or serious infections