Bacterial sepsis refers to symptomatic bacteremia, with or without organ

dysfunction. Sepsis is commonly defined as the presence of infection in

conjunction with the systemic inflammatory response syndrome (SIRS); severe
sepsis, as sepsis complicated by organ dysfunction; and septic shock, as sepsisinduced acute circulatory failure characterized by persistent arterial hypotension
despite adequate volume resuscitation and not explained by other causes.
Essential update: CDC-recommended catheter-care procedure cuts
sepsis rate in dialysis
In a study of hemodialysis patients from 422 facilities, a new catheter-care
procedure recommended by the US Centers for Disease Control and Prevention
(CDC) proved to be more effective than usual care in reducing bloodstream
infection risk in hemodialysis.[1, 2]
Patients in the study, all of whom were undergoing hemodialysis with central
venous catheters (CVCs), received either usual catheter care or treatment with
the newly recommended procedure, which involves exit-site care incorporating
the use of 2% chlorhexidine with 70% alcohol swab sticks, as well as the use of
70% alcohol pads to scrub the hub of the catheter.
According to the report, the CDC-recommended procedure reduced the rate of
bloodstream infections and intravenous (IV) antibiotic starts by 20%.
Signs and symptoms
The history and physical examination may suggest the likely source of the septic
process and thereby help determine the appropriate antimicrobial therapy.
General signs and symptoms may include the following:

Fever, with or without shaking chills

Impaired mental status (in the setting of fever or hypoperfusion)

Increased breathing rate due to respiratory alkalosis

Warm or cold skin, depending on the adequacy of organ perfusion and

dilatation of the superficial vessels of the skin

The following factors suggest an IV line infection:

An infected central line site; peripheral venous lines are almost never
involved, and arterial lines are rarely associated with bacteremia

Elimination of other potential sources, in conjunction with long-term IV line

placement

The following factors suggest a gastrointestinal (GI) or genitourinary (GU)

infection:

History of antecedent conditions predisposing to perforation or abscess

Abdominal pain Diffuse pain (suggesting pancreatitis or generalized

peritonitis), right upper quadrant (RUQ) tenderness (gallbladder etiology),
right lower quadrant (RLQ) tenderness (appendicitis or Crohn disease), or
discrete left lower quadrant (LLQ) tenderness (diverticulitis)

Abnormalities on rectal examination Exquisite tenderness (suggesting a

prostatic abscess) or an enlarged noninflamed prostate (benign prostatic
hyperplasia)

Pertinent GU findings Antecedent history of pyelonephritis, stone

disease, congenital abnormal collecting system, prostate enlargement, or
prostatic or renal operations or procedures; costovertebral angle
tenderness (suggesting pyelonephritis)

Special considerations include the following:

Elderly patients may present with peritonitis and may not experience
rebound tenderness of the abdomen

An acute surgical abdomen in a pregnant patient may be difficult to

diagnose; the most common cause of sepsis in pregnancy is urosepsis due
to an obstructed urinary tract

Sepsis is usually associated with other conditions, such as the following:

GI tract Liver disease, gallbladder disease, colon disease, abscess,

intestinal obstruction, and GI instrumentation

GU tract Pyelonephritis, intra- or perinephric abscess, renal calculi,

urinary tract obstruction, acute prostatitis or abscess, renal insufficiency,
and GU instrumentation

Pelvis Peritonitis and pelvic abscess

Lower respiratory tract Community-acquired pneumonia (with asplenia),

empyema, and lung abscess

Vascular system Infected IV line or prosthetic device

Heart and cardiac vasculature Acute bacterial endocarditis and

myocardial or perivalvular ring abscess

See Clinical Presentation for more detail.

Diagnosis
Laboratory studies that may be considered include the following:

Complete blood count (CBC) Usually not helpful

Bacterial cultures Blood cultures at admission; culture of the catheter tip

(for suspected central IV line sepsis); nasal cultures (potential marker of
MRSA risk)

Stained buffy coat smears or Gram staining of peripheral blood

Urine studies (Gram stain, urinalysis, and urine culture)

Procalcitonin levels

Imaging modalities that may be helpful include the following:

Chest radiography (to rule out pneumonia and diagnose other causes of
pulmonary infiltrates)

Abdominal ultrasonography (for suspected biliary tract obstruction)

Abdominal CT or MRI (for assessing a suspected nonbiliary intra-abdominal

source of infection or delineating intrarenal and extrarenal pathology)

The following cardiac studies may be useful if acute myocardial infarction (MI) is
likely:

Electrocardiography (ECG)

Cardiac enzyme levels

Invasive diagnostic procedures that may be considered include the following:

Thoracentesis (in patients with substantial pleural effusion)

Paracentesis (in patients with gross ascites)

Swan-Ganz catheterization (for helping manage fluid status and assessing

left ventricular dysfunction in MI; not for diagnosis of sepsis per se)

See Workup for more detail.

Management
Initial management may include the following:

Bed rest or admission to the ICU for monitoring and treatment

Transfer if requisite facilities are not available at the admitting hospital

Initiation of empiric antibiotic therapy, to be followed by focused

treatment

Supportive therapy as necessary to maintain organ perfusion and

respiration

Appropriate antimicrobial therapy depends on adequate coverage of the resident

flora of the organ system presumed to be the source of the septic process, as
follows:

IV line infections Meropenem or cefepime plus additional coverage for

staphylococci; if MRSA is prevalent, addition of linezolid, vancomycin, or
daptomycin; if coagulase-negative staphylococci are recovered, avoidance
of vancomycin if possible; line removal

Biliary tract infections Imipenem, meropenem, or piperacillin

Intra-abdominal and pelvic infections Imipenem, meropenem,

monifloxacin, piperacillin-tazobactam, ampicillin-sulbactam, or tigecycline;
clindamycin or metronidazole plus aztreonam, levofloxacin, or an
aminoglycoside

Urosepsis Aztreonam, levofloxacin, a third- or fourth-generation

cephalosporin, or an aminoglycoside; for enterococci, ampicillin or
vancomycin; for vancomycin-resistant enterococcal urosepsis, linezolid or
daptomycin; for community-acquired urosepsis, levofloxacin, aztreonam,
or an aminoglycoside plus ampicillin; for nosocomial urosepsis, piperacillin,
imipenem, or meropenem

Staphylococcal, pneumococcal, or meningococcal sepsis Nafcillin, an

antistaphylococcal agent, a cephalosporin, a carbapenem, daptomycin, or
linezolid; penicillin G or a beta-lactam

Sepsis of unknown origin Meropenem, imipenem, piperacillintazobactam, or tigecycline; metronidazole plus either levofloxacin,
aztreonam, cefepime, or ceftriaxone

Early surgical evaluation for presumed intra-abdominal or pelvic sepsis is

essential. Procedures that may be warranted depend on the source of the
infection, the severity of sepsis, and the patients clinical status, among other
factors.
See Treatment and Medication for more detail.
Image library
A right lower quadrant abdominal wall abscess and enteric fistula are
observed and confirmed by the presence of enteral contrast in the abdominal
wall.