Did you see the BBC Panorama program about sepsis on television on Monday night? What did you think? Whilst the program, like any other form of media, was selective in what it said in order to tell a story I think it is good that it stirred up the debate around the management of sepsis again. Yes again, as the inadequate treatment of sepsis has been known about for over a decade! This is an area where some progress in the NHS has been made but more still needs to be done.
For me personally it was also great to see some of my old colleagues from Nottingham and the progress they have made in the management of sepsis; they have been working hard on this clinical problem for many years and take it very seriously. Their success is a result of their hard work and they deserve a lot of credit for what they have achieved.
For me personally it was also great to see some of my old colleagues from Nottingham and the progress they have made in the management of sepsis; they have been working hard on this clinical problem for many years and take it very seriously. Their success is a result of their hard work and they deserve a lot of credit for what they have achieved.
So whilst it is good that the subject of sepsis was discussed on BBC Panorama the program highlighted to me a number of problems with the management of septic patients. In particular:
Recognising sepsis and the initial management of the septic patient
I have blogged about this before so I’m not going to go into detail here.
For more information on recognising and managing sepsis see:
Sepsis is not difficult to recognise if you have it as one of your differential diagnoses. If you don’t consider it and disprove it then you will never successfully diagnose and treat it. Doctors have a responsibility to grasp this; it is one of the medical emergencies but, as I find with students coming through my teaching, medical schools are failing to teach this.
Sepsis has an underlying cause
Whilst watching the BBC Panorama program I was struck by how many of the programs contributors (not including the experts from Nottingham) used the term sepsis to mean a specific diagnosis. This is not the case. Sepsis is a group of symptoms and signs that indicate that a patient has a severe infection which is causing body organs to become dysfunctional. Sepsis is the body’s critical failure warning system alerting! The importance here is that ANY infection can cause sepsis; it is in itself NOT a specific diagnosis. Patients can be septic due to community acquired pneumonia (CAP), cellulitis, appendicitis, urinary tract infections (UTI), pancreatitis... these are the diagnosis; sepsis is the consequence.
In many hospitals in the UK the diagnosis of “sepsis” has become the most common reason for giving antibiotics. This is wrong. The most common reasons for giving antibiotics should be the most common bacterial infections such as UTI, CAP and cellulitis but instead these common diagnoses have all become “sepsis”. This is a significant problem; let me explain.
The reason why this is so important is that part of the management of sepsis is known as “source control”. It doesn’t matter how good you are at providing physiological support for a septic patient, if you don’t reverse the underlying cause they will die.
One of the patients in the BBC Panorama program appears to have had a UTI which had initially been managed in primary care before she became more unwell. She was admitted to hospital but when her condition deteriorated the antibiotics that had been prescribed weren’t given for a further three hours. Sadly the lady died within two days. The program discusses the hospitals failure to recognise how unwell this lady was and then having realised this they failed to give her treatment quickly enough. The program identifies that many hospitals are still not giving antibiotics even when they have identified sepsis.
Another story within the BBC Panorama program was about the terrible case of a lady who died from sepsis. Yes, it sounds like the healthcare staff failed to recognise how sick she was; they didn’t spot that she was septic. But further on in the documentary it is said that she had severe abdominal pain and eventually had a laparotomy and lots of dead bowel removed. There was a lot of criticism about not recognising that she was septic and not starting antibiotics quickly enough in this lady BUT I would also add that one of the main criticisms ought to be failing to make a specific diagnosis and then dealing with that diagnosis. It sounds like she had ischaemic bowel and therefore part of her management should have been an urgent laparotomy and bowel resection before she became so unwell. Waiting until she is septic to diagnose an ischemic bowel is never going to end well!
Other examples might be the patient septic from a pulmonary empyema who needs a chest drain to remove the pus, or a patient with necrotising fasciitis who needs surgery to resect the diseased soft tissue. This type of “source control” is essential in the management of septic patients and worryingly it is sometimes delayed or not done at all.
Antibiotics for the underlying cause of sepsis
Another reason why it is important to know the underlying diagnosis leading to sepsis is that the antibiotics for each condition are different. The antibiotics for CAP are different to the antibiotics for peritonitis which are different to the antibiotics for meningitis… but all these diagnoses can cause sepsis:
In the above scenarios it is important to start the patient on the correct treatment otherwise the patient will come to harm even though sepsis has been recognised. For example many hospitals now use IV Piptazobactam PLUS IV Gentamicin (often shortened to P&G) or, if the patient is allergic to beta-lactams, IV Teicoplanin PLUS IV Gentamicin PLUS IV Metronidazole (TM&G) for sepsis. These combinations of antibiotics are used when the source of sepsis is unknown and the doctors want to cover as broad a spectrum of possible causative bacteria as they can. If this was used in the above patients then the following would happen:
Suggesting a “single golden bullet” approach is unfortunately not helpful. Whilst it is important to recognise a septic patient (your patient’s critical failure warning system is alerting) it is also important to realise that there is an underlying reason for the sepsis and that MUST be corrected as part of the management of that septic patient. If you don’t then you are not treating the sepsis.
- There is no clear definition of what sepsis is and healthcare staff in general do not recognise when patients are septic
- Patients are often labelled as septic when they have an alternative diagnosis
- Sometimes doctors forget that sepsis is managed through a combination of procedures but that one of the most important is to reverse the underlying reason for the sepsis
Recognising sepsis and the initial management of the septic patient
I have blogged about this before so I’m not going to go into detail here.
For more information on recognising and managing sepsis see:
- Can you recognise a sick patient
- Sepsis! Are bearded men more attractive than non-bearded men?
- Microbiology Nuts & Bolts Clinical Scenarios - Sepsis
Sepsis is not difficult to recognise if you have it as one of your differential diagnoses. If you don’t consider it and disprove it then you will never successfully diagnose and treat it. Doctors have a responsibility to grasp this; it is one of the medical emergencies but, as I find with students coming through my teaching, medical schools are failing to teach this.
Sepsis has an underlying cause
Whilst watching the BBC Panorama program I was struck by how many of the programs contributors (not including the experts from Nottingham) used the term sepsis to mean a specific diagnosis. This is not the case. Sepsis is a group of symptoms and signs that indicate that a patient has a severe infection which is causing body organs to become dysfunctional. Sepsis is the body’s critical failure warning system alerting! The importance here is that ANY infection can cause sepsis; it is in itself NOT a specific diagnosis. Patients can be septic due to community acquired pneumonia (CAP), cellulitis, appendicitis, urinary tract infections (UTI), pancreatitis... these are the diagnosis; sepsis is the consequence.
In many hospitals in the UK the diagnosis of “sepsis” has become the most common reason for giving antibiotics. This is wrong. The most common reasons for giving antibiotics should be the most common bacterial infections such as UTI, CAP and cellulitis but instead these common diagnoses have all become “sepsis”. This is a significant problem; let me explain.
The reason why this is so important is that part of the management of sepsis is known as “source control”. It doesn’t matter how good you are at providing physiological support for a septic patient, if you don’t reverse the underlying cause they will die.
One of the patients in the BBC Panorama program appears to have had a UTI which had initially been managed in primary care before she became more unwell. She was admitted to hospital but when her condition deteriorated the antibiotics that had been prescribed weren’t given for a further three hours. Sadly the lady died within two days. The program discusses the hospitals failure to recognise how unwell this lady was and then having realised this they failed to give her treatment quickly enough. The program identifies that many hospitals are still not giving antibiotics even when they have identified sepsis.
Another story within the BBC Panorama program was about the terrible case of a lady who died from sepsis. Yes, it sounds like the healthcare staff failed to recognise how sick she was; they didn’t spot that she was septic. But further on in the documentary it is said that she had severe abdominal pain and eventually had a laparotomy and lots of dead bowel removed. There was a lot of criticism about not recognising that she was septic and not starting antibiotics quickly enough in this lady BUT I would also add that one of the main criticisms ought to be failing to make a specific diagnosis and then dealing with that diagnosis. It sounds like she had ischaemic bowel and therefore part of her management should have been an urgent laparotomy and bowel resection before she became so unwell. Waiting until she is septic to diagnose an ischemic bowel is never going to end well!
Other examples might be the patient septic from a pulmonary empyema who needs a chest drain to remove the pus, or a patient with necrotising fasciitis who needs surgery to resect the diseased soft tissue. This type of “source control” is essential in the management of septic patients and worryingly it is sometimes delayed or not done at all.
Antibiotics for the underlying cause of sepsis
Another reason why it is important to know the underlying diagnosis leading to sepsis is that the antibiotics for each condition are different. The antibiotics for CAP are different to the antibiotics for peritonitis which are different to the antibiotics for meningitis… but all these diagnoses can cause sepsis:
- CAP might be treated with IV Amoxicillin PLUS IV Clarithromycin
- Cellulitis might be treated with IV Flucloxacillin
- Meningitis might be treated with high dose IV Ceftriaxone
- UTI might be treated with IV Gentamicin
In the above scenarios it is important to start the patient on the correct treatment otherwise the patient will come to harm even though sepsis has been recognised. For example many hospitals now use IV Piptazobactam PLUS IV Gentamicin (often shortened to P&G) or, if the patient is allergic to beta-lactams, IV Teicoplanin PLUS IV Gentamicin PLUS IV Metronidazole (TM&G) for sepsis. These combinations of antibiotics are used when the source of sepsis is unknown and the doctors want to cover as broad a spectrum of possible causative bacteria as they can. If this was used in the above patients then the following would happen:
- The patient with CAP – P&G would treat some of the possible causes but not Legionella pneumophila, Mycoplasma pneumoniae or Chlamydophila pneumoniae; TM&G would only cover Streptococcus pneumoniae and Staphylococcus aureus (Gentamicin does not get in to the chest well enough to treat pneumonia). In fact the Gentamicin would be completely unnecessary and any side effects or complications such as renal failure or hearing loss would be indefensible
- The patient with cellulitis – P&G would provide less effective treatment for S. aureus in soft tissue; TM&G would treat the cellulitis but the Gentamicin and Metronidazole would be completely unnecessary and any side effects or complications such as renal failure or hearing loss would be indefensible
- The patient with meningitis – neither P&G or TM&G would treat meningitis and the patient would either suffer brain damage or die, either way the choice of antibiotic would be indefensible
- The patient with a UTI – both P&G and TM&G would treat the patient even if there would be unnecessary overlap from the Piptazobactam but the Teicoplanin and Metronidazole would offer no benefit and any side effects or complications such as renal failure or bone marrow suppression would be indefensible
Suggesting a “single golden bullet” approach is unfortunately not helpful. Whilst it is important to recognise a septic patient (your patient’s critical failure warning system is alerting) it is also important to realise that there is an underlying reason for the sepsis and that MUST be corrected as part of the management of that septic patient. If you don’t then you are not treating the sepsis.
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