Sepsis

Sepsis, or septicemia, is more appropriately referred to as a clinical syndrome rather than a primary disease process. Sepsis results from the bacterial invasion of the bloodstream by specific microorganisms or their toxic byproducts. Special mediators, released into the bloodstream by the host (patient), interact with the microbial toxins and produce the physiologic abnormalities that characterize septic shock. Predisposing factors for the development of sepsis include diabetes mellitus, cirrhosis, alcoholism, leukemia, lymphoma, chemotherapy patients, and those who are on total parenteral nutrition. Neonates (under 4 months of age) and the elderly are at greatest risk. The majority of cases actually occur in already hospitalized patients, most of whom have underlying diseases or procedures which render their bloodstreams susceptible to bacterial invasion. Fever, chills, rapid heart and respiratory rate, and altered mentation are common acute manifestations of sepsis. When profound low blood pressure and signs of inadequate organ perfusion develop, the condition is termed septic shock. By this point, cell death and tissure injury occurs, ultimately leading to organ failure. The microorganisms (bacteria) responsible for sepsis most often originate from the gastrointestinal tract. Because of specific cell wall features, they are referred to as gram negative organisms. Other bacteria, such as staphylococcus and pneumococcus, can also cause sepsis but represent only about 5-15% of the total cases. An important cause of neonatal sepsis results from infection with hemophilus influenza type b. Sepsis occurs most commonly as a result of a primary infection in the urinary tract (pyelonephritis), gallbladder and bile ducts (cholangitis), or gastrointestinal tract (e.g. perforated bowel). Sepsis can also occur as a result of a primary lung infection (pneumonia) but this is more uncommon. Other rare sources for sepsis include the skin (cellulitis), bones (osteomyelitis), joints (septic arthritis), and meninges (meningitis). Evaluation will include tests to determine the primary source of bacterial infection. This is an important distinction because the source will dictate (to at least some degree) the type of bacteria most likely involved. Specific antibiotic therapy will be based on this crucial information. General screening will include urinalysis, urine culture, CBC, electrolytes, chest x-ray, and blood cultures. Treatment is with high dose intravenous antibiotics. Despite the introduction of new antibiotic agents the mortality rate of this illness has changed little in the last 20 years. A mortality rate of 25-30% is typical for sepsis, but with the addition of septic shock, the mortality rate can increase dramatically. The additional support of respiration with mechanical ventilation is necessary in advanced cases. Blood pressure maintenance is accomplished with intravenous fluids and special medications. Prognosis is determined by the extent of organ malfunction and the presence of underlying diseases (e.g. leukemia).

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