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Overview

Recently, sepsis has been redefined as: “life-threatening organ dysfunction caused by dysregulated host response to infection” (Singer, 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, 2016)


For patient identification, organ dysfunction can be represented by an increase in the Sequential Organ Failure Assessment (SOFA) score (Vincent, 1996) of two points or more, which is associated with an in-hospital mortality greater than 10 per cent. Patients with septic shock can be identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater AND serum lactate level greater than 2 mmol/L in the absence of hypovolemia (i.e. after adequate fluid resuscitation). This combination is associated with hospital mortality rates greater than 40 per cent (Singer, 2016).
These recent modifications were made in order to better integrate the definitions with evolving concepts of this syndrome. Pending future reports, the definitions and diagnostic criteria for pediatric and neonatal sepsis should be considered similar to adult definitions, inclusive of age-specific cut-off values (Goldstein, 2005; Dellinger, 2013). Maternal sepsis refers to sepsis occurring during pregnancy, childbirth and the puerperium. It encompasses a complicated clinical scenario due to the presence of an additional patient (the fetus) and significant pregnancy-related alterations in cardiorespiratory, immunological and metabolic functions.

Implications


Sepsis is a growing health concern in Canada as well as in the rest of the world (CIHI, 2009; Adhikari, 2010). In Western countries, the incidence of sepsis in adults and children continues to rise despite a significantly decreased, but still unacceptably high, mortality rate of 20 to 30 per cent (Annane, 2003; Dombrovskiy, 2007; Angus. 2001, 2013; Friedman, 1998; Stevenson, 2014; Lagu, 2012; Kaukonen, 2015).
Despite advances in the understanding of the pathophysiology of sepsis, of provider training, better surveillance, monitoring and prompt initiation of therapy, there is still much room for improvement as sepsis remains one of the most deadly emergency department arrival or hospital-acquired conditions (Donald, 2015). Similar to other time-sensitive disorders such as polytrauma, acute myocardial infarction, or stroke, the speed and appropriateness of therapy administered in the initial hours after sepsis develops are likely to influence outcome. These features suggest the opportunity for earlier recognition and management of sepsis in improving the outcomes of these patients (Liu, 2014), which, unfortunately, is often not the case. Indeed, in two studies, timely initiation and completion of adequate sepsis management were only between 40 to 58 per cent and 10 to 43 per cent respectively (Mikkelsen, 2010; Ferrer, 2008). Similar observations have been made for pediatric and maternal sepsis (Safer Healthcare Now! Sepsis, 2015).
Sepsis can be prevented in two ways:


1. Treating infections early and appropriately before they develop into sepsis.
2. Identifying, mitigating or preventing risk factors related either to the patient or as a result of care delivered to them.


Examples of risk factors are:
· Age (higher risk in infants 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).
· 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).


Risk factors for the development of maternal sepsis also include factors affecting the pregnancy itself (home birth in unhygienic conditions, low socioeconomic status, history of pelvic infection or of group B streptococcal infection, poor nutrition, diabetes, anemia, primiparity, prolonged rupture of membranes, prolonged labor), multiple pregnancy, pregnancy-related genital manipulation/procedures, multiple (>5) vaginal examinations in labor, cervical cerclage, amniocentesis, artificial reproductive techniques, obstetrical manoeuvres, unassisted vaginal delivery, caesarean section, preeclampsia and postpartum hemorrhage.


Healthcare-associated infections (HAIs) can lead to sepsis and its deleterious outcomes (Riley 2012). HAIs represent the most common complication affecting hospitalized patients today, with currently five to 10 per cent of patients in acute care hospitals acquiring one or more infections. Catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), surgical site infections (SSI), and ventilator-associated pneumonia (VAP) account for the vast majority of all HAIs. Each year about 8,000 Canadians die from hospital-acquired infections; and 220,000 others get infected (Zoutman, 2003). Failure to comply with evidence-based infection preventive practices for HAIs increases the incidence of hospital-acquired sepsis.

Goal

To decrease the morbidity and mortality from sepsis and to prevent nosocomial sepsis in the hospitalized pediatric and adult population.