The challenges of diagnosing sepsis

The UK Sepsis Trust estimates that every year about 250,000 people in this country develop sepsis, of whom around 25,000 are children. Five people die from the disease every hour and around 25% of survivors develop permanent life-changing effects from the disease. Furthermore, there appears to have been a sharp rise in sepsis-related admissions to hospital in recent years. Data from 133 hospital trusts in England shows that between April 2014 and April 2015, there were 55,171 hospital admissions for the disease and 11,527 deaths. For 2016-2017, there were 77,996 admissions and 15,851 deaths, increases of 41% and 38% respectively. Data from other countries appears to follow a similar pattern.

There are several possible reasons for this increase. Firstly, improved recording methods introduced over the past few years mean that some cases that would previously have been recorded as general infections are now classified as sepsis. Secondly, the UK population is ageing and thus becoming more vulnerable to the types of conditions, such as influenza, pneumonia and urinary tract infections, that commonly lead to sepsis. Finally, antibiotic resistance means that simple infections are becoming harder to treat. Infection by Escherichia coli accounts for up to 40% of sepsis episodes, but more than 40% of E. coli infections show resistance to first-line antibiotics.

Sepsis occurs when the body’s immune system responds abnormally, known as ‘dysregulation’, to infection and damages its own tissues and organs. This can lead to organ failure and ultimately the death of the patient. It is unclear what causes this extreme response to what is normally a simple infection. Sepsis can be triggered by any source of infection but it is most commonly a response to bacterial infections of the lungs, urinary tract, abdominal organs or skin and soft tissues. A wide variety of germs can cause sepsis but the majority of cases arise from infection by common bacteria, which under normal circumstances do not cause illness. The infection can start anywhere in the body and, while it may remain in one area, if it enters the bloodstream it can be transferred to any other part of the body. With prompt treatment, the outcome for most patients is excellent, but if the condition is left untreated, the patient will rapidly deteriorate into organ failure, septic shock and death. However, even with prompt and appropriate treatment, a proportion of patients will still die. This is particularly the case where deep-seated sources of infection, such as abscesses, continue to fuel the condition despite the administration of appropriate antibiotics.

Initially, sepsis can resemble flu, gastroenteritis or a chest infection, with the early symptoms including fever, chills and shivering, an increased heart rate and rapid breathing. Signs of more severe sepsis, or septic shock, include faintness or dizziness, confusion and disorientation, nausea and vomiting, diarrhoea, reduced urination and cold, clammy skin which may also have a pale or mottled appearance. This can lead to problems in diagnosing sepsis in the early stages, as the symptoms are non-specific and mimic those of other less serious illnesses. Therefore, a doctor may not initially suspect sepsis but instead diagnose a less serious type of infection. In these circumstances, appropriate treatment may be delayed until the condition has become much more serious. Furthermore, if sepsis develops in a patient post-operatively or after childbirth, the symptoms can be masked by the pain, raised temperature or changes in blood results that would be expected in these circumstances.  It has been estimated that in one-third of sepsis cases there is a delay in identifying the condition. NHS England predicts that several thousand deaths each year could probably be prevented and is aiming to reduce the mortality rate from its current standing of 20% down to 15%.

In July 2016, NICE Guideline 51 was issued, giving advice on the recognition, diagnosis and early management of sepsis. It sets out the requirements for examinations, tests and investigations that should be conducted if sepsis is suspected and the treatment that should be given. It stipulates that in order to aid diagnosis, inflammatory markers such as C-reactive protein should be measured from a venous blood test and abnormalities in white cell count, creatinine and urea established. A blood culture may also help to identify any blood-borne infection. It also states that for any patient meeting the high-risk criteria for sepsis, a broad-spectrum antibiotic should be given immediately and at least within one hour of the criteria being met.

As the incidence of sepsis has risen, so has the number of medicolegal cases relating to the disease and it is now estimated that sepsis-related claims cost the NHS in the region of £2billion each year. Difficulties in diagnosing the condition can lead to justifiable delays in treatment. Although this might lead to permanent injury or death, it also means that it can be very hard to establish that clinical negligence has occurred. In addition, the rapid progression of the disease makes establishing causation very difficult. Sepsis can also develop even if preventative steps are taken and appropriate medication administered.

Further reading:

Burki, T. K. (2018, November). Sharp rise in sepsis deaths in the UK. The Lancet. Respiratory Medicine. England. https://doi.org/10.1016/S2213-2600(18)30382-5

www.sepsistrust.org

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