This module provides an overview of sepsis, including risk factors, clinical features, and best practices for diagnosis and treatment to inform practice and help advanced practice registered nurses (APRNs) provide optimal care, patient education, and support improved patient outcomes and decreased mortality.
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This module provides an overview of sepsis, including risk factors, clinical features, and best practices for diagnosis and treatment to inform practice and help advanced practice registered nurses (APRNs) provide optimal care, patient education, and support improved patient outcomes and decreased mortality.
By the completion of this learning activity, learners will be able to:
- Discuss the pathophysiology of sepsis.
- Identify the risk factors associated with sepsis.
- Describe the clinical manifestations of sepsis.
- Examine the diagnosis and treatment strategies for sepsis.
- Discuss the complications related to sepsis or its management.
Sepsis is one of the oldest described medical conditions. The term sepsis is derived from the ancient Greek term for “decomposition” or “decay.” The first documented use was in Homer’s poems around 2,700 years ago. Hippocrates used the term around 400 BCE to describe how meat decays and swamps release decomposing gases. He also used the term to describe how infected wounds become purulent. Still, the hypothesis that the host response, not the pathogen, was responsible for sepsis was not developed until the 1900s. The germ theory of disease was developed in the 1800s, which led to the recognition that sepsis originates from invading microorganisms. The first modern definition was attempted in the early 1900s. The term “blood poisoning” has been used for centuries, and it persists as a description of sepsis in the non-medical population. Understanding the actual cause and pathophysiology of sepsis has led to better diagnosis of and treatment for sepsis. Evidence has shown that the manifestations of sepsis can no longer be attributed solely to the infectious agent and the immune response but also to significant alterations in coagulation, immunosuppression, and organ dysfunction. Therefore, sepsis is defined as a clinical syndrome that has biological, physiological, and biochemical abnormalities caused by a dysregulated response to an infection (Berg & Gerlach, 2018; Gyawali et al., 2019).
Epidemiology
Sepsis is the body’s response to an infection and can lead to life-threatening complications. Given that anyone can get an infection and any infection can lead to sepsis, timely and accurate diagnosis and management of sepsis is critical. According to the World Health Organization (WHO), sepsis acquired in health care settings is one of the most common adverse events during care delivery. It is estimated that there are 48.9 million cases of sepsis annually worldwide. In addition, there are approximately 11 million sepsis-related deaths, accounting for 20% of all worldwide deaths. Almost half of these cases occur in children, with approximately 20 million cases and 2.9 million deaths occurring in those under 5 years old. Regional disparities regarding sepsis also exist globally, with approximately 85% of cases and deaths occurring in low- and middle-income countries (Centers for Disease Control and Prevention [CDC], 2023; WHO, 2023).
Sepsis is the most common cause of admissions to intensive care units (ICUs) and also the most common cause of death in adults admitted to ICUs in the US (Gauer et al., 2020). Although the management of sepsis has improved, the condition’s incidence is increasing as more drug-resistant organisms emerge. This increased incidence can also be attributed to patients being discharged from the hospital faster and possibly before manifestations of sepsis are apparent. According to the CDC, 1 in 3 patients who die in a hospital will die of sepsis (CDC, 2023). Every year, more than 1.7 million Americans develop sepsis, and almost 350,000 of these patients die during their hospitalization or are discharged to hospice. Sepsis is one of the most expensive diagnoses to treat in the US and accounts for more than $38 billion annually (CDC, 2023; Hollenbeak et al., 2023).
Sepsis and septic shock commonly occur in the US, and most cases begin before a patient enters the health care system. One cohort study of US adults who had sepsis and septic shock explored what types of health care exposures occurred during the 30 days before hospitalization (Fay et al., 2020). Most of the patients in the study (90.3%) were found to have community-onset sepsis (diagnoses within 3 days of hospital admission), and 60.7% of those patients had recent encounters with the health care system. The researchers found that 24.1% of patients had an outpatient encounter within 7 days of admission, and 42% of patients had received medical treatment, including antimicrobials, chemotherapy, wound care, dialysis, or surgery in the month before developing sepsis. The researchers concluded that early recognition and standardized treatment upon admission are important; however, exposures as opportunities to prevent sepsis (Fay et al., 2020).
Pathophysiology
Sepsis is a complex process that usually begins with a bacterial, fungal, or viral infection. Most of the time, sepsis results from a gram-positive bacterial infection. However, there has been an increased incidence of sepsis associated with gram-negative bacteria, viruses, and fungal infections, which more commonly occur in immunocompromised patients. Organisms that often cause sepsis include gram-negative (Klebsiella pneumoniae[K. pneumoniae], Pseudomonas aeruginosa[P. aeruginosa], and Escherichia coli[E. coli]) and gram-positive (Staphylococcus aureus [S. aureus] and Streptococcus pyogenes[S. pyogenes]) bacteria. Infections with antimicrobial-resistant organisms confer a higher risk of developing sepsis. Common antimicrobial-resistant organisms include vancomycin-resistant Enterococcus(VRE), carbapenem-resistant Enterobacterales (CRE [K. pneumoniae, E. coli, P. aeruginosa]), methicillin-resistant S. aureus(MRSA), and penicillin-resistant Streptococcus pneumoniae (S. pneumoniae). The incidence of fungal sepsis has increased over the past decade but remains lower than bacterial sepsis. Viruses can also cause sepsis, including influenza A and B, respiratory syncytial virus (RSV), human metapneumovirus, parainfluenza virus types 1 to 3, coronavirus, adenovirus, enterovirus, and rhinovirus. In about half of all sepsis cases, cultures are negative, and a causative organism is not identified (Fay et al., 2020; Hinkle et al., 2021; Neviere, 2023).
Sepsis exists on a continuum of severity, ranging from infection and bacteremia to sepsis and septic shock. A sepsis infection can progress to a critical situation over several days. As the infection advances, the pathological changes occur faster and become more severe. Control and prevention of sepsis are easier to achieve early in the infectious process, as sepsis that is not recognized early with quick intervention contributes significantly to the progression of septic shock, multiple organ dysfunction syndrome (MODS), and death. The risk of mortality can also range from moderate to substantial depending on the pathogen, host factors, and timeliness of recognition and treatment initiation. Although the site of infection is important to determine, as many as 30% of patients who have sepsis will never have an identifiable site of infection (Hinkle et al., 2021; Neviere, 2023).
An infection that is localized rarely leads to sepsis and shock. A healthy immune system and inflammatory response will confine and eliminate the invading organism when the invasion starts, preventing the infection from becoming worse or more widespread. White blood cells (WBCs) around the infection will secrete cytokines that trigger local inflammation, summoning other WBCs to kill invading or
