5 ways to manage sepsis

Sepsis or “severe infection” has returned as a major cause of death in inpatients, and disability among survivors, according to a new issue brief from the Center for Healthcare Research & Transformation (CHRT).  

Recent national work in 3 different data sets, with different approaches to measuring sepsis, all confirm one theme: sepsis is the major proximal cause of death in today’s hospitals, according to Theodore Iwashyna, MD, PhD, research scientist, Center for Clinical Management Research, Ann Arbor Veterans Affairs Health System, and associate professor of internal medicine, University of Michigan.

Dr Iwashyna

“People develop infections for lots of different reasons, including many chronic conditions such as cancer, stroke and heart disease,” Dr Iwashyna said. “But infections play a pivotal and often neglected role.  If we can better treat that sepsis, we can meaningfully extend the patient’s lives.”

The issue brief, which describes trends in hospitalization rates by diagnosis and by charges for admissions, from 2007 to 2011 in Michigan and the United States, found that between 2007 and 2011, hospital discharge rates for septicemia rose 62% in Michigan. This upward trend is not unique to the state. Nationally, hospital discharge rates rose 57% over the same period of time, and resulted in $74.2 billion in total septicemia diagnoses charges in 2011.

Udow-Phillips

“The key-and most surprising-finding is the state’s dramatic increase in hospitalizations for septicemia, which can cause the life-threatening condition severe sepsis,” said CHRT Director Marianne Udow-Phillips.

“We cannot say with absolute certainty what is the source of the increase, but we believe it is likely reflective of an important shift upward in the disease burden of severe sepsis, as well as changes in coding and recognition,” Udow-Phillips. “What we do know is that early identification and early intervention, with antibiotics and fluids, is essential to survival.”

Treating chronic pain is a significant issue that will only rise as our nation’s population ages, Udow-Phillips said. “There is an urgent case for finding better ways for treating pain,” she said.

Based on the issue brief, Dr Iwashyna offers 5 recommendations to manage sepsis:

• Make sure broad-spectrum IV antibiotics are rapidly available for when severe sepsis is reasonably suspected. Even an hour delay in delivery of appropriate antibiotics can result in a 7% increase in mortality once shock has arrived, but good early antibiotics prevent shock.

• Be liberal with antibiotics up front; but ruthlessly de-escalate in 3 to 5 days once the crisis has passed.

• Empiric treatment is necessary for severe sepsis. In the outpatient setting, it is appropriate to culture, then treat once the cultures show an organism to target. “In severe sepsis, we do not have that time,” said Dr Iwashyna. “Instead, the right strategy is treat broadly early, to make sure you cover all plausible pathogens-within reason-then narrow back down once cultures come back."

• Aggressive hydration with IV fluids should often go with aggressive early antibiotics.

• Sepsis is a major driver of inpatient delirium. Be careful of patients going home on antipsychotics that were being used as new inpatient anti-delirium medications, but should have been stopped on discharge.

“Formulary managers should really examine the trends in chronic disease and make sure that the formulary designs they oversee reflect the changes in disease burden among the population,” Udow-Phillips said.

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