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 malaise, 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, preferably within 6 hours following recognition.

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

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.

The 2016 consensus definitions marked a shift away from the previous systemic inflammatory response syndrome (SIRS) definition, which classified sepsis as two or more of the following in the context of infection: temperature >101°F (38.3°C) or <96.8°F (36.0°C); tachycardia >90 bpm; tachypnea >20 breaths/minute or PaCO₂ <32 mmHg; hyperglycemia (blood glucose >140 mg/dL [>7.7 mmol/L]) in the absence of diabetes mellitus; acutely altered mental status; leukocytosis (WBC count >12,000/microliter); leukopenia (WBC count <4000/microliter); or a normal WBC count with >10% immature forms.[2]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

In the first international consensus definitions, which date from 1991, severe sepsis was defined as sepsis associated with organ dysfunction, hypoperfusion, or hypotension; septic shock was defined as sepsis with hypotension despite adequate fluid replacement.[2]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

However, 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