CDC Report Tackles Sepsis

Health Letter, June 2017

By Azza AbuDagga, M.H.A., Ph.D.

In June 2016, sepsis led to the death of the esteemed boxer and activist Muhammad Ali.[1] The decision of the champion’s family to disclose sepsis as the cause of death has likely raised public awareness of this serious medical condition.[2]

However, many Americans remain unaware that sepsis is a major public health challenge: It is the second most common reason for hospitalization and the most expensive condition treated in hospitals, accounting for nearly $24 billion in annual hospital spending.[3]

Sepsis also kills more than 258,000 Americans and millions more around the globe every year.[4] Worldwide, sepsis kills more people than breast cancer, prostate cancer and HIV infection combined.[5]

A report released this past August by the Centers for Disease Control and Prevention (CDC) in Morbidity and Mortality Weekly Report examined sepsis in hospitals and emphasized prevention, early recognition and treatment of this condition.[6]

What is sepsis?

Sepsis is a serious medical condition caused by the body’s excessive immune response to an infection.[7] If the body is not able to control this immune response, a drop in blood pressure, tissue damage, organ failure, and, in severe cases, death can quickly ensue.

Certain people with infections have a high risk of developing sepsis, including older adults, infants, individuals who have compromised immune systems and individuals with chronic medical conditions (such as diabetes).[8] Although it is much less common, even healthy individuals can develop sepsis from simple cuts or burns that are not cleaned appropriately.

Health care professionals can easily miss early signs of sepsis in a patient. The highly publicized story of a 12-year-old boy named Rory Staunton is one such case.[9] In 2012, emergency room doctors in a New York hospital sent Rory home with just Tylenol when he presented with fever and vomiting after he cut his arm while playing at his school gym. The boy died from sepsis complications three days later.

Sepsis symptoms may include shivering, fever or feeling very cold; extreme pain or discomfort; clammy or sweaty skin; confusion or disorientation; shortness of breath; and rapid heartbeat.[10] However, many of these symptoms also occur with other conditions, making it difficult to recognize sepsis in its initial stages.

There is no specific diagnostic test for sepsis; instead, cultures of the blood and body fluids are performed to determine the presence of infection. Health care professionals often have to rely on their clinical judgment to diagnose sepsis.

Treatment

Sepsis is a medical emergency, so early recognition and treatment are critical to avoid a fatal outcome. Patients with sepsis usually are treated in the intensive care unit to treat or prevent low blood pressure and organ failure.

Antibiotics must be started as soon as possible to treat the underlying infection. A 2006 study showed that administering an effective antibiotic in the first hour of sepsis-related low blood pressure is linked to an 80 percent survival rate and that each hour of delay in the initiation of such therapy over the subsequent six hours is associated with an average decrease in survival of 8 percent.[11]

Patients with sepsis usually receive intravenous fluids to prevent or treat low blood pressure and oxygen therapy to maintain normal blood oxygen levels. Patient status is monitored constantly, and treatment is changed as needed. It may be necessary to use a machine to assist with breathing or dialysis to manage acute kidney failure. Sometimes surgery is required to remove infected tissue.

The CDC report [12]

A team of CDC and other researchers reviewed hospital medical records for a random sample of patients who had been diagnosed with sepsis at four general hospitals in New York from October 2012 to September 2015.

The patient sample was comprised of 246 adults (aged 18 or older), 48 children (aged one to 17) and 31 infants (under one year of age). The median ages for adult patients and children were 69 years and 12 years, respectively.

The majority of adult patients (97 percent) had chronic conditions: 35 percent had diabetes, 32 percent had cardiovascular disease (including coronary artery disease, peripheral vascular disease or congestive heart failure), 23 percent had chronic kidney disease and 20 percent had chronic obstructive pulmonary disease. Congenital heart disease was the most common accompanying condition in infants (affecting 23 percent), whereas cognitive deficits or cerebral palsy were the most common conditions in children (affecting 38 percent).

The most frequent infections leading to sepsis among the study patients involved the respiratory tract, urinary tract, skin or gastrointestinal tract. The specific germs that caused the infection that led to sepsis were not identified in one third of the patients.

The researchers determined that for the majority (nearly 80 percent) of patients included in their review, the sepsis began before the patients were admitted to the hospital.

Furthermore, 72 percent of the patients had either used health care services in the month preceding hospital admission or had chronic conditions that likely required frequent contact with the health care system before admission.

A quarter of the patients included in the review died during hospitalization for sepsis, including 26 percent of adults and 22 percent of infants and children.

Implications

Sepsis prevention efforts traditionally have been focused on infection control programs in hospitals and long-term care facilities. The CDC report’s findings that the majority of sepsis cases begin somewhere other than a hospital and that many sepsis patients have health visits before admission highlight the importance of prevention and early recognition and treatment of sepsis outside of hospitals.

The report recommends that routine health care visits, such as doctor’s office visits, be considered opportunities to reduce the risk of infections that lead to sepsis. This involves appropriate use of hand hygiene and protective equipment by health care professionals to limit the spread of germs among patients. Additionally, because pneumonia is among the most common infections that cause sepsis, health care professionals should recommend pneumococcal vaccination for high-risk patients. This is particularly important given the suboptimal vaccination rates in the U.S., which persist despite the fact that vaccination has been shown to have saved thousands of lives.

The CDC instructs patients to prevent infections that lead to sepsis by cleaning wounds and practicing good hygiene (such as hand washing). If patients suspect that they have sepsis, they should not assume that their doctors have considered it. Instead, the CDC website advises patients to ask, “Could it be sepsis?”


References

[1] Tinker B. What killed Muhammad Ali? CNN. June 9, 2016. http://www.cnn.com/2016/06/09/health/muhammad-ali-parkinsons- sepsis/. Accessed May 10, 2017.

[2] Sepsis Alliance News. Sepsis Alliance mourns loss of boxing legend Muhammad Ali to sepsis at age 74. June 4, 2016. http://www.sepsis.org/sepsis-alliance-news/sepsis-alliance-mourns-loss-boxing-legend-muhammad-ali-sepsis-age-74/. Accessed May 10, 2017.

[3] Torio CM, Moore BJ. National inpatient hospital costs: The most expensive conditions by payer, 2013. HCUP statistical brief #204. May 2016. https://www.hcup- us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.pdf. Accessed May 10, 2017.

[4] Sepsis Alliance News. Sepsis Alliance mourns loss of boxing legend Muhammad Ali to sepsis at age 74. June 4, 2016. http://www.sepsis.org/sepsis-alliance-news/sepsis-alliance-mourns-loss-boxing-legend-muhammad-ali-sepsis-age-74/. Accessed May 10, 2017.

[5] Vincent JL. Increasing awareness of sepsis: World sepsis day. Crit Care. 2012;16(5):152.

[6] Novosad SA, Sapiano MR, Grigg C, et al. Vital signs: Epidemiology of sepsis: Prevalence of health care factors and opportunities for prevention. MMWR Morb Mortal Wkly Rep. 2016;65(33):864-869.

[7] Chang HJ, Lynm C, Glass RM. JAMA patient page. Sepsis. JAMA. 2010;304(16):1856.

[8] Centers for Disease Control and Prevention. Sepsis fact sheet. https://www.cdc.gov/sepsis/pdfs/sepsis-fact-sheet.pdf. Accessed May 10, 2017.

[9] Dwyer J. An infection, unnoticed, turns unstoppable. The New York Times. July 11, 2012. http://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html?_r=0&utm_source=huffingtonpost.com&utm_medium=referral&utm_campaign=pubexchan. Accessed May 10, 2017.

[10] Centers for Disease Control and Prevention. Sepsis fact sheet. https://www.cdc.gov/sepsis/pdfs/sepsis-fact-sheet.pdf. Accessed May 10, 2017.

[11] Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596.

[12] Novosad SA, Sapiano MR, Grigg C, et al. Vital signs: Epidemiology of sepsis: Prevalence of health care factors and opportunities for prevention. MMWR Morb Mortal Wkly Rep. 2016;65(33):864-869.