Sepsis (patient information)

For the WikiDoc page for this topic, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Jason Le, B.S.[2]

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. It is not synonymous with bacteremia or with infection confined to the bloodstream. Septic shock is a subset of sepsis with profound circulatory and cellular/metabolic abnormalities associated with a substantially increased risk of death.^[1]

Sepsis may develop from infection at any anatomical site. Clinical manifestations reflect both the source of infection and developing organ dysfunction. Important findings may include:

• Fever or hypothermia
• Tachycardia or other circulatory abnormalities
• Tachypnea or respiratory distress
• New or worsening confusion or altered mental status
• Hypotension or other evidence of circulatory impairment
• Reduced urine output or other evidence of acute kidney injury
• Hypoxemia or other evidence of respiratory dysfunction
• Skin or soft-tissue findings suggesting an infectious source

No single symptom, physical finding, laboratory test, or biomarker establishes or excludes sepsis. Clinical assessment should consider suspected infection together with evidence of acute organ dysfunction.^[1][2]

Suspected sepsis requires urgent medical assessment, particularly when infection is accompanied by new organ dysfunction, altered mental status, breathing difficulty, markedly reduced urine output, or circulatory instability. Septic shock is a medical emergency.^[3]

Diagnosis is clinical and requires assessment for both infection and acute organ dysfunction. Evaluation commonly includes:

• Assessment of airway, breathing, circulation, mental status, and perfusion
• Identification of a probable infectious source
• Blood cultures and other appropriate microbiologic specimens when this can be performed without clinically important delay in antimicrobial therapy
• Complete blood count and metabolic/renal assessment
• Assessment of lactate when clinically indicated
• Evaluation for organ dysfunction and complications of sepsis
• Source-directed diagnostic testing and imaging when indicated

A negative culture does not exclude sepsis. Microbiologic testing should be interpreted in the context of the clinical syndrome and prior antimicrobial exposure.^[4]

The Sequential Organ Failure Assessment (SOFA) score is used to characterize organ dysfunction in the Sepsis-3 framework. The Surviving Sepsis Campaign recommends against using qSOFA compared with SIRS, NEWS, or MEWS as a single screening tool for sepsis. qSOFA may identify patients at increased risk of poor outcomes, but should not be used as the sole diagnostic or screening tool.^[1][4]

In the Sepsis-3 framework, septic shock is operationally identified in a patient with sepsis who requires vasopressors to maintain a mean arterial pressure of at least 65 mm Hg and has a serum lactate level greater than 2 mmol/L despite adequate volume resuscitation. This clinical state is associated with an in-hospital mortality greater than 40%.^[1]

Management requires simultaneous treatment of infection, circulatory and respiratory abnormalities, and the source of infection. Patients with sepsis or septic shock generally require hospital-based care; critically ill patients may require intensive care unit management.^[3]

Antimicrobial therapy should be selected according to the suspected source of infection, severity of illness, prior antimicrobial exposure, allergy history, local resistance patterns, and individual risk factors for resistant organisms.

For adults with possible septic shock or a high likelihood of sepsis, antimicrobials should be administered immediately, ideally within 1 hour of recognition (strong recommendation). For possible sepsis without shock, a time-limited rapid investigation is advised, with antimicrobials given within 3 hours if concern for infection persists (weak recommendation).^[4][3]

Antimicrobial therapy should be reassessed as microbiologic and clinical information becomes available. De-escalation is recommended once pathogen and susceptibility information permit narrowing of therapy. Treatment duration should generally be the shortest effective duration supported by the infection source, clinical response, and available evidence.^[3]

For sepsis-induced hypoperfusion or septic shock, at least 30 mL/kg of intravenous crystalloid is suggested within the first 3 hours (conditional recommendation, low certainty), using balanced crystalloids in preference to normal saline. The initial volume should be calculated using actual body weight, with adjusted or ideal body weight used when BMI is greater than 30 kg/m².^[3][4]

Hydroxyethyl starch and other starch-based fluids should not be used for resuscitation. Subsequent fluid administration should be guided by dynamic measures of fluid responsiveness and frequent reassessment to reduce the risks of both inadequate resuscitation and fluid overload.^[4][3]

Patients with persistent circulatory failure may require vasopressor therapy. Norepinephrine is the first-line vasopressor (strong recommendation, high-quality evidence), titrated to a mean arterial pressure of at least 65 mm Hg. Vasopressin is added when the norepinephrine dose reaches approximately 0.25–0.5 µg/kg/min, and epinephrine is added for shock refractory to norepinephrine and vasopressin.^[4][3]

Supplemental oxygen and ventilatory support may be required for sepsis-associated respiratory failure. Patients who develop acute kidney injury or other severe organ dysfunction may require organ-supportive therapies, including renal replacement therapy when clinically indicated.^[4][2]

IV corticosteroids are conditionally recommended for adults with septic shock requiring vasopressors. The usual regimen is IV hydrocortisone 200 mg/day, divided every 6 hours or administered by continuous infusion, for 7 days or until ICU discharge, with or without enteral fludrocortisone 50 micrograms daily. High-dose, short-course regimens (>400 mg/day hydrocortisone equivalent for <3 days) are specifically recommended against (strong recommendation). Corticosteroids accelerate shock reversal and may modestly reduce mortality, with increased risks including hyperglycemia and hypernatremia.^[3][5]

Recombinant human activated protein C (drotrecogin alfa) should not be used to treat sepsis. The PROWESS-SHOCK trial showed no mortality benefit, prompting worldwide market withdrawal in 2011.^[6][7]

Host-response-directed therapies remain an evolving area of research and should not be presented as established standard treatment without supporting evidence.^[8]

When an anatomic source of infection requires intervention, prompt source control is an essential component of treatment. Source control may include drainage of an infected collection, removal of an infected device, or an appropriate surgical or procedural intervention. When source control is required, intervention should occur as soon as medically and logistically feasible. The 2026 Surviving Sepsis Campaign guideline suggests early source control, ideally within 6 hours of diagnosis of sepsis or septic shock requiring source control (conditional recommendation, very low certainty evidence), with earlier intervention preferred when feasible.^[3][4]

Sepsis can cause or worsen dysfunction of multiple organ systems. Complications may include:

• Septic shock
• Acute kidney injury
• Respiratory failure
• Cardiovascular dysfunction
• Neurologic dysfunction and altered mental status
• Coagulation abnormalities
• Prolonged critical illness and functional impairment
• Death

Sepsis and septic shock are potentially fatal conditions. Prognosis depends on the severity and duration of organ dysfunction, the infectious source, the patient's underlying health, and the timeliness and effectiveness of treatment.^[2][3]

Recovery may extend beyond hospital discharge. Adult sepsis survivors can experience persistent physical, cognitive, and mental-health sequelae and may have increased risk of rehospitalization or death after the acute illness.^[9][10]

Survivors should be assessed for physical, cognitive, and emotional sequelae after sepsis, with appropriate follow-up and referral for persistent problems.^[4]