Sepsis: Introduction

Overview and Implications

Sepsis is defined as: "life-threatening organ dysfunction caused by dysregulated host response to infection" (Singer et al., 2016). It affects neonatal, pediatric, and adult patients worldwide. Differentiated from an uncomplicated infection by virtue of the dysregulated host response and acute organ dysfunction, sepsis can present as or progress to septic shock, recently redefined as: "a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone." (Singer et al., 2016). Maternal sepsis is a life-threatening condition defined as an organ dysfunction caused by an infection during pregnancy, delivery, puerperium, or after an abortion (Escobar et al., 2020).

Healthcare-associated infections (HAIs) can lead to sepsis and its deleterious outcomes (Riley & Wheeler, 2012). Failure to comply with evidence-based infection preventive practices for HAIs increases the incidence of hospital-acquired sepsis.

HAIs account for a large proportion of patient safety incidents in Canada. Every year, it is estimated that 220,000 Canadian patients (approximately one in nine) will develop an infection during their stay in hospital. Complicating the problem is the fact that many HAIs are caused by antimicrobial-resistant organisms (AROs), which make them difficult to treat. Although progress has been made to prevent and control ARO-related HAIs, much work remains to be done. Globally and in Canada, the steps taken to mitigate antimicrobial resistance (AMR) are relatively limited (MacLaurin et al., 2020). The Public Health Agency of Canada (PHAC) estimates that approximately two per cent of patients admitted to large, academic Canadian hospitals will have acquired an infection with an ARO during the course of their hospital stay (Mitchell et al., 2019) and that at any given time, three to 10 per cent of patients who are hospitalized in Canada will either be infected or be a carrier of an ARO (Martin et al., 2019).

Canada continues to lag behind other OECD countries on sepsis following abdominal surgery (CIHI, 2019b). In 2019, the Canadian in-hospital sepsis rate was 3.9 per 1,000 patients (CIHI, 2019a).  Sepsis affects approximately 1.7 million adults in the United States each year and potentially contributes to more than 250,000 deaths. Various studies estimate that sepsis is present in 30 to 50 per cent of hospitalizations that culminate in death. The high burden of sepsis and the perception that most sepsis-associated deaths are preventable with better care has catalyzed numerous sepsis performance improvement initiatives in hospitals around the world (Rhee et al., 2019).  

It has been reported in a recent study that hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives (Rhee et al., 2019).

Recommendations for guiding care for adults with critical or severe Coronavirus associated sepsis have been developed by the Surviving Sepsis Campaign Coronavirus Disease 2019 panel and will be updated as necessary (Alhazzani et al., 2020). 

Risk Factors

Examples of risk factors are:

• Age (higher risk in neonates and elderly persons than in other age groups).
• Chronic diseases with/without severe organ dysfunction.
• Immunodeficiency.
• Immunosuppressive agents.
• Inappropriate use of antibiotics.
• The presence of implanted medical devices (intravascular or other).
• Pregnancy.
• Prematurity.
• Infection is more likely to occur when the normal anatomy is altered by a process – benign or malignant - that either obstructs a normal passage (e.g., calculous cholecystitis, prostatitis) or breaks and enters a previously sterile system (e.g., skin breakdown by trauma, dermatological conditions).
• Patients unable to communicate their symptoms often present later in their illness (i.e., often with sepsis) (CPSI et al., 2015).