When sepsis strikes

Sepsis is a potentially life-threatening condition triggered by an infection, and must be detected and treated early.

Everyone suffers from infections from time to time. Various parts of the body can be involved, for example, the respiratory tract, skin and urinary tract.

The organisms are usually bacteria and viruses, but may occasionally be parasites or fungi.

The body’s response to an infection is to limit it to one site. White blood cells travel to the infection site, and a series of reactions occur to fight the infection and prevent its spread.

The process, called inflammation, is aimed at removing the harmful organisms and damaged cells, and start the healing process.

Inflammation can be acute or chronic. The former lasts a few days, though sometimes, a few weeks. The latter can last several months, or even, years, and is due to failure to eliminate the cause of the acute inflammation, or it could be due to a chronic persistent microbe of low intensity. An example of the former is acute upper respiratory tract infection, and the latter, tuberculosis.

When the immune system is weak or the infection is virulent, the infection spreads through the bloodstream to other parts of the body and causes widespread inflammation.

The body’s response injures its own tissues and organs. There may be a marked decrease in blood pressure that affects oxygen transport to vital organs like the heart, kidneys and brain. If untreated or treated inadequately, sepsis leads to multiple organ failure and death.

Infections associated with sepsis are infections of the lung, urinary tract, gallbladder, abdomen, pelvis, skin, and even, flu, in some cases.

The most common infection sites that lead to sepsis are the lungs, urinary tract, abdomen and pelvis.

However, there are instances where the source and cause of the sepsis cannot be identified.

According to the Malaysian Registry of Intensive Care, head injury, sepsis and community-acquired pneumonia were the three most common diagnoses leading to admission to intensive care units (ICU) in Health Ministry hospitals in 2011.

The in-hospital mortality rates of these patients were 25.2%, 58.9% and 40.6% respectively.

Risk factors

Everyone is at risk of sepsis. Some patients with sepsis do not require hospitalisation, although they feel ill. When sepsis is severe, immediate hospitalisation is necessary.

Sepsis is more common in those at risk – the very young and very old; the pregnant; those who have chronic conditions such as diabetes; those who just had surgery, accidental injuries and/or with invasive devices such as drips, catheters and ventilators; those whose immunity are weakened, such as HIV patients or those on treatment that weakens the immunity (long-term steroids, cancer chemotherapy); and those who are hospitalised for some other condition.

Hospital-associated infections are more serious, as many of the bacteria are resistant to many commonly-used antibiotics.

Managing sepsis

The features of sepsis include fever, chills, shivering, tiredness, poor appetite, rapid heart rate and rapid breathing.

The features of severe sepsis, which is life-threatening, include difficulty breathing; abnormal heart function; cold, clammy skin; abrupt change in mental state (confusion, disorientation); slurred speech; loss of consciousness; markedly decreased urine output; and decreased platelets.

The blood pressure in septic shock is very low and does not respond adequately to fluid replacement.

The diagnosis of sepsis is clinical, and the tests include that of blood and body fluids, such as urine, wound secretions, respiratory secretions and stool; imaging, including x-ray, ultrasound, computerized tomography (CT) scan; and kidney, heart and lung function tests.

Early diagnosis is essential to determine the type of infection, its location, and its impact on body functions.

Early treatment is necessary to stop the sepsis from progressing, reduce damage and decrease the risk of death. Treatment is dependent on the site and cause of the initial infection, the organ affected and the damage caused.

Severe sepsis or septic shock can only be treated in a hospital and may require admission to the ICU. This is because the chances of death in severe sepsis and septic shock is about four and six in every 10 affected persons respectively.

The mainstay of treatment for sepsis, severe sepsis or septic shock is antimicrobials upon diagnosis, even before the infectious agent is identified.

Initially, broad-spectrum antimicrobials, which are effective against a variety of organisms, are administered intravenously.

After getting the blood results, the antimicrobials may be changed to one that is more appropriate to the specific cause.

Although antibiotics are not effective against viruses, parasites or fungi, it is likely that they will be started anyway because it would be too dangerous to delay treatment.

Once the specific cause is identified, the appropriate antimicrobial will be given.

Antiviral agents may be given at the outset if there is strong suspicion that it is the cause of the sepsis.

The source of the infection, when identified, will be treated. Collections of pus will be drained. Surgery may be needed to remove pus and infected tissue.

Oxygen is administered through a mask or tubes in the nostrils if blood oxygen levels are low.

Those who have severe difficulty breathing would have a tube inserted into their trachea that is connected to a machine that helps breathing mechanically (i.e. a ventilator).

Medicines called vasopressors are prescribed for low blood pressure to help increase it by stimulating the muscles that pump blood around the body and narrowing or constricting blood vessels.

Extra fluids may also be given intravenously to help increase blood pressure.

Sufficient intake of food and liquids is essential. The former is done by inserting a thin tube up the nose and down into the stomach, or by inserting a drip to provide food and fluids.

Intravenous fluids are usually given in severe sepsis or septic shock to prevent dehydration and kidney failure. A catheter will be inserted into the bladder to monitor urinary output so that renal failure can be detected early.

Painkillers may be needed. Medicines to keep the patient drowsy or asleep may be prescribed to ensure sufficient rest and make the patient more comfortable.

Other treatments that could be instituted include blood transfusion, steroids, insulin and dialysis for impaired kidney function.

The duration of treatment depends on each patient’s individual circumstances.

It is advisable for anyone with features of an infection to seek medical attention, particularly if there are risk factors.

Anyone who develops features of sepsis after surgery, hospitalisation or an infection is advised to seek immediate medical care.

Early diagnosis and treatment will lead to full recovery. Late diagnosis and treatment may lead to disability, and even, death.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. The views expressed do not represent that of any organisation the writer is associated with.