In Spain sepsis affects 50,000 people and is responsible for 17,000 deaths each year1. Early detection of infection, before patients must be admitted to intensive care, is essential to trigger appropriate treatment and improve outcome. A commonly used strategy among doctors to identify a suspected infection and evaluate severity has been to use criteria defined by experts. The Systemic inflammatory response syndrome (SIRS) criteria, which rely on the degree of hypoperfusion and inflammatory response to determine the presence and degree of the infection, have long served as a reference in clinical practice and research. However, many practitioners have insisted the SIRS are not sensitive and specific enough. In fact, the controversy over these old criteria pushed the international consensus responsible for setting sepsis criteria to issue new measures earlier this year.
These experts updated the definitions by putting the focus on low blood pressure, high respiratory rate and altered mentation as means to recognise sepsis and septic shock for patients inside and outside the ICU. The new criteria have been named the qSOFA (Quick SOFA Score), and many thought they would help gain time in patient management.
However, the authors of a more recent study have concluded that the qSOFA does not help to evaluate patients in the Emergency Department who are not yet in need of critical care (qSOFA, SIRS, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients Outside the ICU. Churpek, Snyder, Han, Sokol, Pettit, Howell, Edelson).
Thus things are back to square one and there hasn’t been much progress in speeding the identification of effective criteria for early diagnosis, Dr Ines Rubio-Perez from La Paz Hospital in Madrid, explained. ‘The change of parameters was meant to improve everything. But, according to the new study, the qSOFA are not that good in diagnosing patients on time; actually if you have to monitor altered mentation it means it’s a little late already,’ she said. ‘qSOFA detect mortality very well but they are not early criteria. So there’s not much difference between the old and the new, and many people are discussing the utility of these criteria in the emergency setting.’
Rubio-Perez, a colorectal surgeon with special interest in surgical infections, will join a symposium on intra abdominal infection diagnosis and treatment update during the meeting. In her opinion the absence of a gold standard in sepsis management is due to the complexity of the disease. ‘What happened again with the Sepsis 3 consensus is that things don’t work as well in practice as in theory. Sepsis is a complex process and it’s complicated to define uniform standards. We still need to revise our criteria, or make a combination between the SIRS, the qSOFA or other scores.’
To speed things up, Madrid hospitals started the Code Sepsis initiative, similar to Code Stroke, and in which healthcare members are put on alert in case of suspected sepsis to trigger the appropriate chain of action. ‘Initiatives like the Surviving Sepsis campaign and Code Sepsis can offer simple pathways and identification systems to diagnose patients with sepsis early. This must be an institutional and multidisciplinary effort. A few other regions in Spain have done the same with successful results,’ Rubio-Perez pointed out. Sepsis is a common scenario in abdominal emergencies, for instance in peritonitis or appendicitis, and treatment relies on antibiotic and surgical therapy.
Having suffered a previous super resistant bacterial infection, i.e. being a carrier, augments risk for a patient to present with a clinical infectionInes Rubio-Perez
Besides finding the appropriate diagnostic criteria, the other challenge in sepsis management is antibiotic resistance. ‘A patient presenting with an infection due to multi-resistant bacteria may not respond to usual treatment, as the initial antibiotic may not cover appropriately. This significantly increases morbimortality.’
Rubio-Perez, PhD was on the topic, suggests looking at risk factors, such as previous antibiotic intake, or recent hospitalisation, prolonged stay in long-term care, or residential home, a daily hospital visit for dialysis, and other clinical factors, including diabetes, immune suppression, repeated urinary tract infection, etc. ‘Having suffered a previous super resistant bacterial infection, i.e. being a carrier, augments risk for a patient to present with a clinical infection,’ she added.
Complications increase in post-surgery patients who develop a nosocomial infection. Treatment may be only one or two antibiotics, because of resistance, and this may also substantially augment morbidity.
After completing her residency in general surgery in 2012 at Princesa Hospital in Madrid, Ines Rubio-Perez MD became a staff surgeon in the colorectal surgery unit at La Paz University Hospital. Her research activities include the study of clinical profiles and risk factors of multi-resistant infections in surgical patients – the subject of her PhD thesis in 2015. She is a member of the board of the Surgical Infections Section in the Spanish Surgical Association (AEC), and Councillor and Educational Committee member of the Surgical Infection Society - Europe (SIS-E), where she strives to involve surgeons in the knowledge and importance of infections.
1 The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.