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Content Update
October 31, 2017
Lower Mortality with Rapid Completion of 3-hour Sepsis Bundle: Inappropriate antimicrobial selection and delays in initiating therapy are associated with increased mortality in patients with sepsis. Sepsis "bundles" and practice guidelines are associated with reduced mortality in sepsis patients. A recent publication involving more than 40,000 patients with sepsis and septic shock at 149 New York hospitals reported on a sepsis protocol initiated within 6 hours of arrival that included a 3-hour bundle of care (blood cultures, broad-spectrum antibiotics, and lactate measurement). Risk-adjusted in-hospital mortality was higher in patients when the sepsis bundle was completed in 12 hours vs. the goal of within 3 hours. Longer time to administration of antibiotics was also associated with higher in-hospital mortality.
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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK
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For the chapter in the Wells Handbook, please go to Chapter 45. Sepsis and Septic Shock.
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KEY CONCEPTS
Gram-negative organisms are isolated in 50% to 62% of patients with severe sepsis or septic shock, followed by gram-positive bacteria in 37% to 47%, anaerobic organisms in 5%, and fungi in 8% to 19%.
Candidemia is a major cause of morbidity and mortality. Candida albicans remains the most common pathogen (45.6%); however, non–albicans Candida species collectively is more frequently isolated (54.4%).
Sepsis presents a complex pathophysiology, characterized by the activation of multiple overlapping and interacting cascades leading to systemic inflammation, a procoagulant state, and decreased fibrinolysis.
Mortality rates with sepsis are higher for older patients with preexisting disease, intensive care unit (ICU) care, and multiple organ failure.
Prompt initiation of one or more parenteral antibiotics within 1 hour of recognition of septic shock and severe sepsis without septic shock is required and the regimen should be assessed daily for potential de-escalation.
A significant volume of fluid leaks from the vasculature occurs with sepsis, and initial fluid resuscitation with large volumes of fluid is required. Crystalloid solutions are generally recommended for fluid resuscitation because of the absence of any clear benefit with colloids solutions in addition to the lower cost of crystalloids.
Norepinephrine is the preferred vasopressor to correct hypotension in septic shock, and epinephrine should be considered the first alternative to patients intolerant to norepinephrine.
Implementation of protocolized, quantitative resuscitation bundle within 6 hours of recognition of sepsis-induced hypoperfusion has been shown to decrease the mortality rates as well as the ICU length of stay.
A blood glucose level less than 180 mg/dL (10 mmol/L) is recommended for the majority of critically ill patients to reduce morbidity and mortality without the detrimental effects associated with hypoglycemia.
IV hydrocortisone is recommended for adult patients with septic shock whose blood pressure is unresponsive to fluids and vasopressors.
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Sepsis and severe sepsis continue to pose major healthcare burden. The Nationwide Inpatient Sample years 2003 to 2009 reported hospitalizations with sepsis claims including septicemia sepsis, severe sepsis, and septic shock increased ...