INFECTION DIAGNOSTICS :: SEPSIS


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Understanding sepsis: The importance of biomarkers in early diagnosis


By Patusa Mayfield, MBA-HCM, MT(ASCP) I


t starts with a common infection leading to a chain reaction and deterioration of a person’s health. The symptoms are aggressive — including an accelerated heart rate, fever, shivering, confusion or disorientation, shortness of breath, and extreme pain. It’s common to hear patients say, “It feels like I am going to die.” When an infection persists or gets worse, and it could lead to sepsis and septic shock. Sepsis, a life-threatening organ dys- function in response to infection, affects 47–50 million people worldwide each year with approximately 11 million deaths.1 With an overall mortality rate of 15–30% leading to 30–50% of all in-hospital mortality.2


Sepsis is the most expensive


condition in modern medicine. The worldwide incidence of sepsis contin- ues to increase, putting a high financial burden on society and the healthcare system.2


than prostate cancer, breast cancer, and HIV combined.3,4


More individuals die of sepsis Because anyone can get


an infection, anyone can develop sepsis. There are several factors contributing to the high toll of sepsis. When it comes to sepsis treatment, time to source control matters. For every hour treatment is delayed, there is up to a 7.9% increase in mortality and as much as a 10% increase in the odds of one-year mortality.5,6


Early


and accurate identification of sepsis is needed for successful treatment and a positive outcome.5


Most cases of sepsis are diagnosed in the emergency department (ED) with 87% of cases starting prior to admission.7 When patients arrive at the ED, clinicians


26 DECEMBER 2022 MLO-ONLINE.COM


are tasked with quickly triaging patients based on limited diagnostic information. As the patient struggles to understand what is happening, the ED clinicians face the challenging task of assessing and determining a course of action. Sepsis identification relies on a combination of clinical suspicions based on nebulous patient symptoms with laboratory test results that can indicate multiple condi- tions (see Figure 1). Unfortunately, failure to recognize sepsis early in the disease course often leads to worse outcomes.8 Sepsis diagnosis requires confirma- tion of an underlying infection through a positive blood culture, but these tests can take two to three days for results9 — too long for defining a sepsis care pathway. Moreover, the overlap of clini- cal symptoms between sepsis and other, non-infectious inflammatory conditions can confound the diagnosis. The challenge is to diagnose sepsis


as early as possible, even when a severe infection is not suspected. The answer may be leveraging an existing, routine test to include an indication of sepsis. By enhancing the most common laboratory test ordered by emergency physicians, a complete blood count (CBC) with an early sepsis indication may allow antibiotics to be administered sooner while not adding new burdens to physicians, nurses, labo- ratories, or the patient.


Current tests The challenges surrounding sepsis diag- nosis have led to sepsis commonly being under-or over-diagnosed.10


suspected sepsis patients includes basic vitals—heart and respiratory rates, oxygen saturation levels, blood pressure, and temperature. Because septic patients often show signs of change in mental status7


and speech patterns,11 these are


also evaluated. The Systemic Inflamma- tory Response Syndrome (SIRS) criteria were introduced in 1992 as a tool to help diagnose sepsis. Under SIRS, diagnosis of sepsis requires the presence of two or more of four basic criteria (tachycardia, tachypnea, hyperthermia, or hypother- mia (>38°C or <36°C) and changes in white blood count levels).12


In 1994, the


Sequential Organ Failure Assessment (SOFA) score, based on platelet counts, creatinine levels, respiration, cognition, and liver and renal changes, was intro- duced as a way to describe the degree of organ failure of critically ill patients.13 In 2016, an international task force in- troduced the newest definition for sepsis: the Sepsis-3 (Sep-3) criteria. Under the Sep-3 criteria, sepsis is an infection with two or more of the previously defined SOFA points, whereas septic shock is sepsis with vasopressor-dependent hypotension and a lactate level greater than two.14


The same task force also intro- Screening of


duced the quick SOFA (qSOFA) criteria to identify patients at high risk for a poor outcome. qSOFA is a simple test with only three components: respiratory rate >22 breaths/min, altered mental state, and systolic blood pressure <100 mmHg.15 Each component receives one point, and a score >2 has been found to be predictive of all-cause mortality outside of the ICU.15


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