Sepsis in adults

Sepsis can progress rapidly to multiorgan failure and shock, and is often fatal. Survival is dependent on a high index of suspicion of sepsis, early recognition, and timely intervention.

Findings are generally nonspecific and secondary to primary infection. They include leukocytosis, tachypnea, tachycardia, and altered mental status.

Patients with evidence of sepsis, including signs of organ dysfunction, require immediate hospital assessment.

Empiric broad-spectrum antibiotic therapy (based on the most probable pathogens and site of infection) should be administered as soon as possible, and preferably within the first hour if the patient is progressing to shock.

Blood cultures, as well as cultures of all potentially infected body fluids, should be obtained as indicated by symptoms and the risk profile of the patient, ideally before the initiation of antimicrobial treatment.

Any source of infection should be controlled as a matter of urgency within 6-12 hours following recognition.

Evidence of shock should be identified and treated with immediate intravenous fluid challenges, if present. Shock that fails to respond to fluid challenges necessitates consideration of vasopressors and/or inotropes and urgent critical care admission.

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. https://jamanetwork.com/journals/jama/fullarticle/2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com The definition of sepsis was updated in 2016 following publication of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. https://jamanetwork.com/journals/jama/fullarticle/2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com This recommended that organ dysfunction should be defined using the Sequential (or Sepsis-related) Organ Failure Assessment (SOFA) criteria or the "quick" (q)SOFA criteria. However, these are late indicators of deterioration and evidence does not support use of these as single screening tools for sepsis.[2]Nieves Ortega R, Rosin C, Bingisser R, et al. Clinical scores and formal triage for screening of sepsis and adverse outcomes on arrival in an emergency department all-comer cohort. J Emerg Med. 2019 Oct;57(4):453-60.e2. http://www.ncbi.nlm.nih.gov/pubmed/31500993?tool=bestpractice.com [3]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/fulltext/2021/11000/surviving_sepsis_campaign__international.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com [4]Haydar S, Spanier M, Weems P, et al. Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis. Am J Emerg Med. 2017 Nov;35(11):1730-3. http://www.ncbi.nlm.nih.gov/pubmed/28712645?tool=bestpractice.com In practice, it is important to diagnose suspected sepsis at an earlier stage in any patient with presumed infection who is evaluated as being at risk of deterioration based on clinical assessment and/or an early warning score or risk stratification tool.[3]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/fulltext/2021/11000/surviving_sepsis_campaign__international.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com [5]Churpek MM, Snyder A, Han X, et al. Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for detecting clinical deterioration in infected patients outside the intensive care unit. Am J Respir Crit Care Med. 2017 Apr 1;195(7):906-11. https://www.atsjournals.org/doi/10.1164/rccm.201604-0854OC http://www.ncbi.nlm.nih.gov/pubmed/27649072?tool=bestpractice.com [6]Fernando SM, Tran A, Taljaard M, et al. Prognostic accuracy of the Quick Sequential Organ Failure Assessment for mortality in patients with suspected infection: a systematic review and meta-analysis. Ann Intern Med. 2018 Feb 20;168(4):266-75. http://www.ncbi.nlm.nih.gov/pubmed/29404582?tool=bestpractice.com

The widely-accepted 2016 consensus definitions marked a shift away from the previous systemic inflammatory response syndrome (SIRS) definition and the first 1991 international consensus definition, which described severe sepsis as sepsis associated with organ dysfunction, hypoperfusion, or hypotension; and septic shock as sepsis with hypotension despite adequate fluid replacement.[7]Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250-6. http://www.ncbi.nlm.nih.gov/pubmed/12682500?tool=bestpractice.com

The 2016 Third International Consensus Group (Sepsis-3) definitions state that the term "severe sepsis" should be made redundant in light of the revisions to the definition of sepsis.[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. https://jamanetwork.com/journals/jama/fullarticle/2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com Septic shock has also been redefined as a subset of sepsis in which there is co-existence of: persistent hypotension requiring vasopressors to maintain mean arterial pressure ≥65 mmHg; and serum lactate >2 mmol/L (>18 mg/dL).[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. https://jamanetwork.com/journals/jama/fullarticle/2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com

Septic shock indicates profound circulatory, cellular, and metabolic deterioration, and is associated with a greater risk of mortality than with sepsis alone.[1]Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. https://jamanetwork.com/journals/jama/fullarticle/2492881 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com