Patients with sepsis in Infectious Diseases Department in years 1997-2010 - epidemiology and clinical features - Epidemiological Review

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ABSTRACT

,1752'8&7,21Sepsis is a clinical syndrome that complicates severe infection. The incidence of sepsis is increasing worldwide.

$,0of the study was evaluation of demographic data and clinical picture of patients hospitalized in Infectious Diseases Ward with a diagnosis of sepsis and severe sepsis.

0$7(5,$/$1'0(7+2'6 7KHUHWURVSHFWLYHVWXG\LQFOXGHGSDWLHQWVZLWKVHSVLVDQGVHYHUHVHSVLVKRVSLWDO-L]HGLQ 5(68/766HSVLVZDVGLDJQRVHGLQRISDWLHQWVDQGVHYHUHVHSVLVLQRISDWLHQWV7KHPRUWDOLW\UDWH LQSDWLHQWVZLWKVHYHUHVHSVLVZDV%ORRGFXOWXUHVZHUHSRVLWLYHLQFDVHV*UDPSRVLWLYHEDFWHULD ZHUHLVRODWHGPRVWIUHTXHQWO\±7KHPRVWFRPPRQVRXUFHRILQIHFWLRQRYHUDOOZDVSQHXPRQLD 2GRQWRJHQLFLQIHFWLRQVDQGXULQDU\WUDFWLQIHFWLRQVGRPLQDWHGLQSDWLHQWVZLWKVHSVLVRI SDWLHQWVGHYHORSHGEDFWHULDOPHQLQJLWLV &21&/86,216'HVSLWHDGYDQFHVLQGLDJQRVWLFVDQGWUHDWPHQWVHSVLVLVVWLOODPDMRUPHGLFDOSUREOHPZLWKKLJK PRUWDOLW\3DWLHQWVZLWKVHYHUHVHSVLVDQGPHQLQJLWLVVKRXOGEHWUHDWHGLQ,&8VHWWLQJ'HFD\HGWHHWKVKRXOGEH considered as a potential source of sepsis of unknown origin.

.H\ZRUGVsepsis, epidemiology, clinical features, decayed teeth

INTRODUCTION

Sepsis is a clinical syndrome that complicates se-YHUHLQIHFWLRQ,WLVFKDUDFWHUL]HGE\WKHFDUGLQDOVLJQV of inflammation occurring in tissues that are remote from the infection. The incidence of sepsis is increasing worldwide (1).

,Q86$WKHFXUUHQWLQFLGHQFHRIVHSVLVLVDWOHDVW patients per 100,000 people, whereas for severe sepsis LWLVEHWZHHQDQGSDWLHQWVSHUSHRSOH In Poland it is estimated that ca 53 patients per  GHYHORS VHYHUH VHSVLV DQQXDOO\  6HYHUH VHSVLVUHPDLQVDVHULRXVPHGLFDOSUREOHPDQGLVRQH of the main causes of death with mortality rate of 30-50%. Patients who survive sepsis also appear to have a persistent decrement in the quality of their life (3).

The main risk factors of sepsis development are age, FRQFRPLWDQWGLVHDVHVGLDEHWHVPDOLJQDQF\DOFRKRO-ism), immunoincompetency (4).

In Poland patients with sepsis are hospitalized either in Infectious Diseases Wards or in ICU in dependence on patients clinical status.

The aim of the study was evaluation of demographic data and clinical picture of patients hospitalized in In-fectious Diseases Ward with a diagnosis of sepsis and severe sepsis.

CHARACTERISTICS OF ANALYZED PATIENTS AND METHODS

7KHUHWURVSHFWLYHVWXG\LQFOXGHGSDWLHQWVGLDJ-nosed with sepsis and severe sepsis and hospitalized in the Department of Infectious Diseases and Neuroinfec-WLRQVRI0HGLFDO8QLYHUVLW\LQ%LDO\VWRNLQ\HDUV 7KH'HSDUWPHQWLVDUHJLRQDOUHIHUHQFHFHQWUHIRU &HQWUDO1HUYRXV6\VWHPLQIHFWLRQVLQFOXGLQJEDFWHULDO meningitis.

Medical documentation of patients was analyzed with regard to demographic information, physiological YDULDEOHV FRPRUELGLWLHV ODERUDWRU\ PHDVXUHPHQWV VXVSHFWHGVRXUFHRILQIHFWLRQDQGSUHYLRXVDQWLELRWLF XVH%DVLQJRQWKHDYDLODEOHGDWDVHYHULW\RILOOQHVV in the form of the sequential organ failure assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score in the moment of pa-tient’s admission were counted. In the cases of individual patients referred to the department from other medical FHQWHUVDYDLODEOHUHVXOWVRIEDVLFODERUDWRU\WHVWVDQG cultures received from the medical institution of the prior hospitalization were used.

Sepsis was defined as presence of two or more SIRS FULWHULDDERG\WHPSHUDWXUHJUHDWHUWKDQƒ&RU ORZHUWKDQƒ&DKHDUWUDWHJUHDWHUWKDQEHDWV SHUPLQXWHWDFK\SQHDPDQLIHVWHGE\DUHVSLUDWRU\ UDWHJUHDWHUWKDQEUHDWKVSHUPLQXWHRUK\SHUYHQWLOD-WLRQDVLQGLFDWHGE\D3D&2RIOHVVWKDQPP+J DQDOWHUDWLRQLQWKHZKLWHEORRGFHOOFRXQWVXFKDV DFRXQWJUHDWHUWKDQFXPPDFRXQWOHVVWKDQ 4 000/cu mm, or the presence of more than 10 percent immature neutrophils) and a infectious process (5,6).

6HYHUHVHSVLVZDVGHILQHGDVVHSVLVFRPSOLFDWHGE\ RUJDQG\VIXQFWLRQVXFKDVDUWHULDOK\SR[HPLD3D2 ),2DFXWHROLJXULDXULQHRXWSXWP/NJ KURUPPRO/IRUDWOHDVWKUVFUHDWLQLQHLQFUHDVH PJG/FRDJXODWLRQDEQRUPDOLWLHV,15!RU $377 ! VHFV LOHXV DEVHQFH  RI ERZHO VRXQGV WKURPERF\WRSHQLD SODWHOHW FRXQW  / K\-SHUELOLUXELQHPLDSODVPDWRWDOELOLUXELQ!PJG/RU PPRO/

Septic shock was defined as a state of acute cir-FXODWRU\ IDLOXUH FKDUDFWHUL]HG E\ SHUVLVWHQW DUWHULDO K\SRWHQVLRQXQH[SODLQHGE\RWKHUFDXVHV+\SRWHQVLRQ LVGHILQHGE\DV\VWROLFDUWHULDOSUHVVXUHEHORZPP +J0$3RUDUHGXFWLRQLQV\VWROLFEORRGSUHVVXUH

RI ! PP +J IURP EDVHOLQH GHVSLWH DGHTXDWH YROXPHUHVXVFLWDWLRQLQWKHDEVHQFHRIRWKHUFDXVHV for hypotension (5).

6WDWLVWLFDODQDO\VLVZDVSHUIRUPHGXVLQJ6WDWLVWLFD software. Normality was evaluated using Shapiro-Wilk test. *URXSVZHUHFRPSDUHGE\0DQQ:KLWQH\WHVWDQG&KL VTXDUHGWHVW3YDOXHZDVFRQVLGHUHGVWDWLVWLFDOO\ significant.

The ethics committee approval to conduct this study was not required.

RESULTS ,QWKHWRWDOJURXSRISDWLHQWVZLWKVHSVLV ZHUHPDOHDQGIHPDOHWKHPHDQ DJHZDV\HDUVUDQJHSDWLHQWV ZHUHLQKDELWDQWVRIWRZQVDQGSDWLHQWV±LQ-KDELWDQWVRIFRXQWU\WDE,'HPRJUDSKLFDQGFOLQLFDO data of analyzed patients).

6HSVLVZDVGLDJQRVHGLQSDWLHQWVDQG severe sepsis - in 55 patients (51.4%). In 6 patients the GLVHDVHZDVFRPSOLFDWHGE\VHSWLFVKRFNSD-tients (19.6%) required ICU treatment. The mortality rate in patients with severe sepsis was 30.9%. None of the SDWLHQWVZLWKVHSVLVGLHG,QWKHDJHJURXS\HDUVVHSVLV ZDVGLDJQRVHGLQSDWLHQWVDQGVHYHUHVHSVLV±LQ SDWLHQWLQWKHDJHJURXS\HDUV±LQ DQGSDWLHQWVUHVSHFWLYHO\LQDJHJURXS \HDUV±LQDQGSDWLHQWVLQDJH JURXS!\HDUV±LQDQGSDWLHQWV ,QWKHDJHJURXS\HDUVQRQHRIWKHSDWLHQWVGLHGLQ DJHJURXS\HDUV±SDWLHQWVGLHGLQDJH JURXS\HDUV±SDWLHQWVGLHGLQDJHJURXS !\HDUV±SDWLHQWVGLHG 0HDQGXUDWLRQRIKRVSLWDOVWD\ZDV“GD\V 7KHPHDQ62)$VFRUHZDV,QWKHVHSVLVJURXS WKHVFRUHUDQJHGIURPWRSRLQWVZKLOHLQVHYHUH sepsis group – from 0 to 9 points. The mean APACHE ,,VFRUHDWDGPLVVLRQZDV“,WZDVVLJQLILFDQWO\ KLJKHULQWKHVHYHUHVHSVLVJURXS“YV“ SDWLHQWVKDGDERG\WHPSHUDWXUHKLJKHU WKDQƒ&DQGSDWLHQWVZHUHK\SRWKHUPLF ƒ&$KHDUWUDWHJUHDWHUWKDQEHDWVSHUPLQXWH ZDVREVHUYHGLQFDVHV/HXNRF\WRVLVJUHDWHU WKDQPPZDVGHWHFWHGLQFDVHVDQG OHXFRSHQLDPPLQHSLVRGHVWKHSUHV-ence of immature neutrophils was detected in 9 cases 0HDQ:%&FRXQWZDVFHOOVPP3 _{and it} was significantly higher in severe sepsis. Mean CRP OHYHOZDVPJODQGLWZDVVLJQLILFDQWO\KLJKHULQ SDWLHQWVZLWKVHYHUHVHSVLV0HDQDOEXPLQFRQFHQWUDWLRQ ZDVJGODQGLWZDVVLJQLILFDQWO\ORZHULQSDWLHQWV with severe sepsis. The mean concentration of glucose ZDVPJGODQGZDVQRQVLJQLILFDQWO\KLJKHULQ patients with severe sepsis. Aminotransferases activity was significantly higher in patients with severe sepsis. 0HDQKHPRJORELQFRQFHQWUDWLRQZDVJGODQG it was significantly lower in patients with severe sepsis.

,QSDWLHQWVWKHLQIHFWLRQZDVFRPPXQLW\ acquired while in 11 (10.3%) it was nosocomial.

3DWKRORJLFDORUJDQLVPVZHUHLVRODWHGIURPEORRG FXOWXUHVLQFDVHV*UDPSRVLWLYHEDFWHULD ZHUHLVRODWHGPRVWIUHTXHQWO\±IROORZHGE\ *UDPQHJDWLYHEDFWHULD±Stapylococcus aureusZDVWKHPRVWFRPPRQSDWKRJHQRYHUDOO± PHWKLFLOOLQUHVLVWDQWS. aureus (MRSA) ac-FRXQWHGRIVWDSK\ORFRFFDOVHSVLV

In 3 cases more than 1 pathogen was isolated. $PRQJ  SDWLHQWV ZLWK QHJDWLYH EORRG FXOWXUHV   UHFHLYHG DQWLELRWLFV EHIRUH KRVSLWDOL]DWLRQ 7DEOH,,VKRZVWKHSDWKRJHQVLVRODWHGIURPEORRGFXO-tures of patients with sepsis and severe sepsis.

Patients with sepsis ₄₃₁

No 3

7KHHPSLULFWUHDWPHQWZDVDGHTXDWHLQRI cases (45.5% in nosocomial infections and 63.5% in community-acquired infections).

The most common source of infection overall was SQHXPRQLDFDVHV±,WZDVWKHPDLQVRXUFH of infection in patients with severe sepsis (16 cases ±ZKLOHRGRQWRJHQLFLQIHFWLRQVSDWLHQWV± DQGXULQDU\WUDFWLQIHFWLRQVSDWLHQWV± GRPLQDWHGLQSDWLHQWVZLWKVHSVLVWDE,,,

SDWLHQWVGHYHORSHGEDFWHULDOPHQLQJLWLV It was significantly more frequent in patients with severe VHSVLVFDVHV±WKDQLQSDWLHQWVZLWKVHSVLV FDVHV±:DWHUKRXVH)ULGHULFKVHQV\QGURPH ZDVREVHUYHGLQFDVHV

&KURQLF FRPRUELGLWLHV ZHUH SUHVHQW LQ  RI SDWLHQWV7KHPRVWFRPPRQFRPRUELGLWLHVZHUHK\- SHUWHQVLRQKHDUWGLVHDVHVDX-toimmunological diseases 14 (13.1%) and alcoholism WDE,

The group of patients who died consisted of 11 PHQDQGZRPHQLQWKHPHDQDJHRI“\HDUV

The median time of hospitalization in this group was 4 days (range 1-36 days). At admission 5 of these patients IXOILOOHGDOO6,56FULWHULDSDWLHQWV±FULWHULDDQG SDWLHQWV±FULWHULD7KHPHDQ$3$&+(,,VFRUHLQ WKLVJURXSZDV“SDWLHQWVKDGSRVLWLYHEORRG culture: S.aureus MSSA – 3 patients, S.aureus MRSA – SDWLHQWVRWKHUSDWKRJHQVDUHOLVWHGLQ7DEOH,,

SDWLHQWVLQWKLVJURXSGHYHORSHGEDFWHULDOPHQLQJL-WLVSDWLHQWV±VHSWLFVKRFNSDWLHQWV',&SDWLHQWV had a history of chemiotherapy due to neoplasmatic GLVHDVHSDWLHQWVKDGDXWRLPPXQRORJLFDOGLVHDVHV SDWLHQWV±GLDEHWHVSDWLHQWV±KHDUWGLVHDVHVDQG patients – hypertension.

After development of respiratory or/and circulatory failure the patients were transferred to ICU.

DISCUSSION

According to some authors over 40% of sepsis cases QHYHUUHTXLUHLQWHQVLYHFDUH

7DEOH, 'HPRJUDSKLFDQGFOLQLFDOGDWDRIDQDO\]HGSDWLHQWVQ 

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Mean age (years) “ “ “ 

Male  34 30 0.34 Female    Country  14 13 0.69 Town    Community acquired     Nosocomial 11(10.3%) 5(9.6%) 6(10.9%) 

Response to empiric treatment    

Mean duration of hospital stay (days) “ “ “ 

'XUDWLRQRIIHYHU!&GD\V “ “ “ 0.55

SOFA score “ “ “ 

APACHE II “ “ “ 

Mortality  0  

Glucose concentration “ “ “ 

MedianWBC count (thousand cells/mm3)    

Mean HGB (g/dl) “ “ “ 

Mean CRP levels(mg/l) “ “ “ 

0HDQDOEXPLQFRQFHQWUDWLRQJGO “ “ “ 

Median AlAT (U/l)    

Median AspAT (U/l)    

FKURQLFFRPRUELGLWLHV Hypertension     Heart diseases    0.5 Autoimmunological diseaases   6(11%)  Alcoholism   6(10.9%) 0.15 'LDEHWHVPHOOLWXV 6(5.6%) 1(1.9%) 5(9.1%) 0.1 Cancer 5(5.6%)  3(5.5%)  Thyroid diseases 5(5.6%)   0.61 Cholelithiasis 6(5.6%)  3(5.5%)  Chronic cholecystitis  1(1.9%) 3(5.5%)  Urolithiasis    0.96

AlAT – Alanine transaminase AspAT - Aspartate transaminase &53±&UHDFWLYHSURWHLQ  :%&±:KLWHEORRGFHOO

In Poland patients with sepsis are usually treated in Infectious Diseases Wards and only patients with cir-culatory and/or respiratory failure are admitted to ICU. Patients analyzed in our study, at least at the moment RIDGPLVVLRQJHQHUDOO\ZHUHLQEHWWHUFRQGLWLRQWKDQ those usually treated in ICU. However patients who GLHGKDG$3$&+(,,VFRUHRI“

In many studies performed in non-ICU settings the reported mortality of patients with severe sepsis was KLJKDQGYDULHGIURPWR7KHPRUWDO-ity in our study for severe sepsis patients was 30.9% which is in accordance with aforementioned studies. Wang et al showed that patients who were admitted to ICU from ER had significantly lower APACHE II score and mortality than patients who were previously treated LQKRVSLWDOZDUGV

A study of Kübler et al showed that average mortal-ity of patients with severe sepsis in polish ICU was ca $XWKRUVFRQFOXGHGWKDWWKHSUREDEOHUHDVRQIRU such high mortality were late referrals of seriously ill SDWLHQWVWRWKH,&8ZKLFKPD\EHDVVRFLDWHGZLWKWRR ORZDYDLODELOLW\RILQWHQVLYHFDUHEHGV,Q3RODQG,&8 EHGVDFFRXQWIRU±RIDOOKRVSLWDOEHGVZKHUHDVLQ :HVWHUQ(XURSH±

According to Martin et al. case fatality rates in-FUHDVHVOLQHDUO\E\DJH$OVRHOGHUO\SDWLHQWVSUHVHQW with more severe course of sepsis and require longer hospitalization (13).

In our study the highest mortality was in patients 41-\HDUVROGZKLOHLQROGHUSDWLHQWV!\HDUV ROGWKHPRUWDOLW\ZDV,WKDVWREHXQGHUOLQHG that, although younger, patients in group 41-60 suffered

from many chronic diseases including neoplasmatic processes and chronic alcoholism. Also in this age group meningitis, septic shock and DIC were more frequent than in patients >60 years old.

7KHDYHUDJHDJHRIRXUSDWLHQWV“\HDUV was lower than in the study from United States (1).

The majority of patients in our study were males. This is in accordance with other studies (6, 13, 14). Martin et al. reported that the risk of sepsis development is ca 30% higher in men than in women (1).

Almost 90% of examined patients had a community-acquired infection. This is in accordance with results DFTXLUHGE\Esteban et al.

As far as source of sepsis is concerned pneumonia dominated in the group with severe sepsis while in the group with sepsis odontogenic and urinary tract infec-tions were the most common sources. Pneumonia was also reported as the most common source of infection E\Esteban et al. (56% of community-acquired infec-WLRQVYVLQRXUVWXG\IROORZHGE\XULQDU\WUDFW LQIHFWLRQVYV

According to Padkin et al. respiratory infections as a FDXVHRIVHYHUHVHSVLVDSSHDUWREHLQFUHDVLQJRYHUWLPH whereas urinary sources are decreasing (14). Kübler et al. reported than in polish ICU the most common VRXUFHRILQIHFWLRQLVDEGRPLQDOFDYLW\IROORZHG E\UHVSLUDWRU\WUDFWLQIHFWLRQV

Odontogenic infections are interesting as they are only rarely considered as a potential source of sepsis. Some authors state that there is no scientific evidence RI UHODWLRQVKLS EHWZHHQ LQIODPPDWLRQ LQ RUDO FDYLW\ (e.g. periapical) and internal organ infections (15).

7DEOH,, %ORRGFXOWXUHUHVXOWVRISDWLHQWVZLWKVHSVLVDQGVHYHUHVHSVLVQ 

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*UDPSRVLWLYH 43      

Staphylococcus aureus (MSSA)     9  0.9

Staphylococcus aureus (MRSA) 6 10.0  6.9 4  0.44

Coagulase-negative staphylococci (CoNS)   5   6.5 

Streptococcus pneumoniae  3.3 1 3.4 1  0.96

Streptococcus group A  3.3 0 0.0  6.5 0.16

Streptococcus group Viridans 3 5.0 3 10.3 0 0.0 

Listeria monocytogenes 1  0 0.0 1  0.33 Enterococcus spp 4   6.9  6.5 0.95 Bacillus cereus 1  0 0.0 1  0.33 *UDPQHJDWLYH 16    9  0.9 Escherichia coli 5   6.9 3   Stenotrophomonas maltophilia 3 5.0 1 3.4  6.5 0.59 Neisseria meningitidis  3.3 1 3.4 1  0.96 Klebsiella pneumoniae 3 5.0  6.9 1  0.51 Klebsiella oxytoca 1  1 3.4 0 0.0 0.3 Ochrobactrum anthropi 1  1 3.4 0 0.0 0.3 Acinetobacter baumani 1  0 0.0 1  0.33 Pseudomonas aeruginosa 1  0 0.0 1  0.33 )XQJL 1  0 0.0 1  0.33 Cryptococcus neoformans 1  0 0.0 1  0.33

Patients with sepsis ₄₃₃

No 3

+RZHYHULWZDVSURYHQWKDWLQWHQVLYHWRRWEUXVKLQJDQG GHQWDOH[WUDFWLRQVFDXVHEDFWHULHPLDDVEDFWHULDHQWHU the circulation through gingival tissue the surrounds the teeth (16).

7KH PHGLDQ QXPEHU RI WHHWK ZLWK FDULHV LQ RXU patients in which odontogenic infection was suspected ZDVUDQJHDQGDPHGLDQRIWHHWKH[WUDFWHGGXU-LQJKRVSLWDOL]DWLRQLQWKLVJURXSZDVUDQJH,Q most cases the teeth that were the source of infection had received a root canal therapy in the past. There was no other potential source of infection and extraction of decayed teeth resulted in rapid improvement of these patients’ clinical status.

High percentage of meningitis in our patients may EHH[SODLQHGE\WKHVSHFLILFLW\RIWKH'HSDUWPHQWZKLFK is a regional reference center for neuroinfections.

Comparison of group of patients with severe sepsis DQGPHQLQJLWLVDQGJURXSZLWKVHYHUHVHSVLVEXWZLWKRXW meningitis showed that deaths were more frequent in WKHILUVWJURXSWKDQLQWKHODWWHUS7KHUHIRUH GHYHORSPHQWRIPHQLQJLWLVPD\EHFRQVLGHUHGDQHJD-tive prognostic factor.

In other studies patients suffering from CNS dys-function in the course of sepsis are also reported to have VLJQLILFDQWO\KLJKHUULVNRIGHDWK

7KHPRVWFRPPRQFKURQLFFRPRUELGLWLHVZHUHK\-pertension, autoimmune diseases, heart diseases, alco-KROLVPGLDEHWHVFDQFHUDQGWK\URLGGLVHDVHV7DEOH, Among these, heart diseases and alcoholism were more frequent in the non-survivors group in comparison to other patients with severe sepsis, although it was on the HGJHRIVWDWLVWLFDOVLJQLILFDQFHS IRUDOFRKROLVP DQGS IRUKHDUWGLVHDVHV

2WKHU FRPRUELGLWLHV KDG OLWWOH HIIHFW RQ SDWLHQWV mortality.

Forsblom et al. and Laupland et al. reported chronic alcoholism as one of the factors influencing IDWDORXWFRPHRIVHYHUHEDFWHUDHPLD$FFRUGLQJ to Schuetz et alGLDEHWHVLVQRWDQHJDWLYHSURJQRVWLF IDFWRUIRUPRUWDOLW\LQVHSVLV

,QRIH[DPLQHGSDWLHQWVEORRGFXOWXUHVZHUH SRVLWLYH,QERWKDQDO\]HGJURXSV*UDPSRVLWLYHEDFWHULD dominated with S.aureus as the most common pathogen.

7KLVLVLQFRQWUDVWWRUHVXOWVUHSRUWHGE\Esteban et al. ZKLFKVKRZHGGRPLQDQFHRI*UDPQHJDWLYHEDFWHULD (FROLZDVWKHGRPLQDQWSDWKRJHQUHVSRQVLEOHIRUFD RILQIHFWLRQV$QRWKHUQRQ,&8EDVHGVWXG\ SHUIRUPHG E\ Sundararajan showed dominance of *UDPSRVLWLYHEDFWHULD,QODUJHVWSROLVKHSLGH-PLRORJLFVWXG\EORRGFXOWXUHV*UDPSRVLWLYH EDFWHULDGRPLQDWHGYV

,QPDQ\,&8EDVHGVWXGLHV*UDPSRVLWLYHEDFWHULD ZHUHPRUHFRPPRQDOWKRXJKSROLVKVWXG\RI Kübler et al. showed slight dominance of Gram negative EDFWHULD

7KHFRPSDULVRQEHWZHHQVHSVLVDQGVHYHUHVHSVLV group showed that patients with severe sepsis had sta-tistically significantly higher CRP concentration. It is in accordance with a study of Suprin et al. who showed that &53FRQFHQWUDWLRQGHSHQGVRQVHYHULW\RIVHSVLV

7KHKHPRJORELQFRQFHQWUDWLRQLQSDWLHQWVZLWKVH-vere sepsis was significantly lower. Anemia in patients ZLWKVHYHUHVHSVLVPD\EHFDXVHGHLWKHUE\KHPRO\VLV RU E\ LQIODPPDWRU\ SURFHVV7KH SDWKRSK\VLRORJ\ of anemia of inflammation is complex and includes UHGXFHGSURGXFWLRQRIHU\WKURSRLHWLQLPSDLUHGERQH marrow response to erythropoietin and decreased red EORRGFHOOVXUYLYDO

$OVRWKHDOEXPLQFRQFHQWUDWLRQZDVORZHULQVH-vere sepsis. Li et al.UHSRUWHGWKDWK\SRDOEXPLQHPLDLQ

SDWLHQWVZLWKVHYHUHVHSVLVLVFDXVHGE\WKHLQFUHDVHG GLVWULEXWLRQUDWHIURPYHVVHOWRWLVVXHDQGWKHLPSURYHG GHFRPSRVLWLRQUDWH

CONCLUSIONS

- Despite advances in diagnostics and treatment sepsis LVVWLOODPDMRUPHGLFDOSUREOHPZLWKKLJKPRUWDOLW\ - Because of high mortality, patients with severe sepsis DQGPHQLQJLWLVVKRXOGEHWUHDWHGLQ,&8VHWWLQJHYHQ if no circulatory or respiratory failure is present.

 'HFD\HGWHHWKVKRXOGEHFRQVLGHUHGDVDSRWHQWLDO source of sepsis of unknown origin.

7DEOH,,,3RWHQWLDOVRXUFHVRILQIHFWLRQQ 

3RWHQWLDOVRXUFHVRIVHSVLV 7RWDOQ  % VHSVLVQ  % VHYHUHVHSVLVQ  % S

Pneumonia    13.5 16  

Urinary tract infection  15.9 11  6 10.9 0.15

Odontogenic infection 16 15.0 13  3 5.5  ,QWHUQDODEVFHVVHV  6.5   5 9.1  $EGRPLQDO  6.5 3  4   Skin infection 5  3   3.6 0.6 i.v. catheters/injections 4  1 1.9 3 5.5 0.34 Infectious endocarditis 4  4  0 0.0  9HUWHEUDORVWHRP\HOLWLV 3    1  0.53 Other/Unknown  19.6 6 11.5 15  

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6. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Confer-ence Committee. American College of Chest Physicians/ 6RFLHW\RI&ULWLFDO&DUH0HGLFLQH&KHVW 1655.  6DQGV.(%DWHV':/DQNHQ31HWDO(SLGHPLRORJ\RI VHSVLVV\QGURPHLQDFDGHPLFPHGLFDOFHQWHUV-$0$   'DQDL30DUWLQ*6(SLGHPLRORJ\RI6HSVLV5HFHQW $GYDQFHV&XUU,QI'LV5HSRUWV±  (VWHEDQ$)UXWRV9LYDU))HUJXVRQ1'HWDO6HSVLV

incidence and outcome: contrasting the intensive care XQLWZLWKWKHKRVSLWDOZDUG&ULW&DUH0HG 

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