Dr. Prachee Sathe, MD, FRCP, FCCCM
Director, ICU , Ruby Hall Clinic, Pune India
This article was featured in "India Today" magazine dated 24 September 2018
"What's happening doctor? He just had fever for 4 to 5 days and now you say he has come to the ICU for admission? Why? He was a healthy person you know!" or take another one, "Doctor, my father is diabetic, had a wound on his foot which was not healing and you see, suddenly he has become drowsy, scanty urine, doesn't even have fever, but WBC is high", look at this third case, "Why would the ICU doctor tell us for my brother with alcoholic pancreatitis that he is in severe sepsis with multi organ failure?". Is there anything common in these patients with diverse medical problems? We have come across such stories sometimes or the other. Monsoon season with tropical fevers adds to the sudden septic condition with organs failing one after another. The worldwide statistics denotes very high incidence of sepsis and mortality along with it. (Sepsis kills up to 5.3 to 6 million people each year). In India, the (INDICAPS 2012) study, based on a sample size of 4,209 ICU patients, across 17 states showed how 26 per cent of the patients in ICUs got admitted because of sepsis. Surprisingly high mortality rate was noticed in patients with sepsis, 42.2 % as opposed to 17% in other non-septic ICU patients. At the same time the survey showed that awareness about sepsis especially in India is abysmally low.
Sepsis can be the clinical manifestation of infections acquired both in the community setting and in health care facilities. Health care-associated infections are one of the adverse events to occur during delivery of care and affect hundreds of millions of patients worldwide every year. Since these infections are often resistant to antibiotics, they can rapidly lead to deteriorating clinical conditions. These can happen due to overgrowth of bacteria which are not sensitive to given antibiotics and immunocompromised status may contribute as well.
Immunity helps us to fight with infections. Sepsis is a life-threatening organ dysfunction caused by a dysregulated immune response to infection. If not recognized early and managed promptly, it can lead to septic shock, multiple organ failure and death. Any infection or even inflammation can cause this. Since definition includes the "dysregulated immune response" as a cause, it is very difficult to predict who may develop septic response.
Anyone affected by an infection can progress to sepsis conditions but some vulnerable populations such as elderly people, pregnant women, neonates, hospitalized patients, and people with immune compromised states like HIV/AIDS, liver cirrhosis, cancer, kidney disease, organ transplant, autoimmune diseases and no spleen, are at higher risk. Antimicrobial resistance is one of the factors.
Sepsis is a medical emergency and can progress fast. However, because of the characteristics of sepsis as a disease condition with multiple causative organisms and its evolving nature over time, people with sepsis can present various signs and symptoms at different times. Warning signs and symptoms include fever or low temperature and shivering, altered mental status, difficulty breathing/rapid breathing, increased heart rate, weak pulse/low blood pressure, low urine output, blue or mottled skin, cold extremities, and extreme body pain or discomfort. Suspecting sepsis is a first major step towards early recognition and diagnosis. Once suspected, recognized clinically, the treatment protocol has to start expeditiously as per the standard international recommendations of the "Surviving Sepsis Guidelines (SSG)" or "sepsis bundles". These protocols have been revised recently, in 2016 and 2018. Initial golden hours for giving IV fluids and antibiotics are most important. If signs of any organ failures start then appropriate support like artificial ventilation or some type of dialysis may be required. Obviously this needs ICU support and may even take a week or 10 days or sometimes a longer stay in the ICU. If the patients are recovering, they can be completely normal post reversal.
If any infective agent or focus is found (which may remain occult in up to 40% cases) antibiotics could be better targeted and surgical removal of the source may be needed. Early IV fluid therapy to improve circulating blood volume status is also important in the initial phase of sepsis management, sometimes requiring strong medicines (vasopressors) to raise the falling BP. Despite appropriate care, as per the standard protocol, death rate or prolonged ICU stay cannot be avoided completely.
There are two main steps to prevent sepsis :
Prevention of infection in the community, involves use of effective hygiene practices, such as hand washing, and safe preparation of food, improving sanitation and water quality and availability, providing access to vaccines, particularly for those at high risk. Appropriate nutrition including breastfeeding for newborns help fight sepsis. Prevention of infection in health care facilities mainly relies on having effective infection prevention and control (IPC) teams. Good hygiene practices in community as well as hospitals including hand hygiene, clean, well-functioning equipment and environment are essential. Appropriate antibiotic treatment can prevent sepsis from becoming life threatening. Clearly, improved hand hygiene practice in healthcare can reduce infection by as much as 50% while in community settings, it can cut the risk of diarrhoea by at least 40%. Vaccinations prevent 2-3 million infection-associated deaths every year.
Early and quick molecular diagnosis of offending infective organism is an important step in research as culture reports take minimum 2-3 days. Since it has been identified that sepsis develops because of "dysregulated immune response" to initial insult, newer technologies to control the exaggerated immune response are being studied and some of them like cytokine/inflammatory molecules removal with blood purification technologies may help in future along with high end research projects to develop newer antibiotics & vaccines is imperative.
Implicitly, sepsis is relevant to other health targets in SDGs. Prevailing scenario of sepsis is precarious and hence, equal contributions are required to tackle this menace from all the stakeholders including international organizations, government of India, pharmaceutical industries, medical experts, scientists, academicians, mass media, NGOs and last but not the least people's participation is of utmost importance to achieve SDGs collectively.