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Table of Contents   
ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 1770-1773
Prognostic factors of sepsis rapid progression in patients admitted to Intensive Care Unit


1 Anti-microbial Resistance Research Center, Iran University of Medical Sciences, Tehran, Iran
2 Department of Surgery, Lorestan University of Medical Sciences, Khorramabad, Iran
3 Department of Geriatric Medicine, Ziaeian Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran
4 Burn Research Center, Iran University of Medical Sciences, Tehran, Iran
5 Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
6 Department of Anatomical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran

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Date of Web Publication11-Jan-2018
 

   Abstract 


Background: Immediate identification and treatment of patients at the risk of developing sepsis would contribute to a more efficient diagnosis. This study aimed to examine the effective determinants bringing about the rapid progression of this disease towards septic shock and severe sepsis. Materials and Methods: This study is a retrospective cross-sectional research on the patients, above 12 years, admitted to one of the hospitals in Tehran. It took 18 months to conduct this study that included merely patients with sepsis. Patients' cases were examined thoroughly, and eventually the progression of their diseases towards septic shock (low blood pressure despite adequate fluid intake) or severe sepsis (organ dysfunction) and related factors were investigated. Results: We included 230 patients, among whom 84 individuals developed septic shock and severe sepsis within 72 h. The Effective factors in the progression of their diseases were old age, high temperature, female sex, vascular catheter-related infections, low serum albumin, and diastolic pressure <52 (P = 0.025, 0.04, <0.001, 0.006, <0.001, and <0.001) respectively. Conclusion: A significant number of patients with sepsis developed septic shock and severe sepsis. Our study indicated that factors such as age, sex, low albumin, and low diastolic pressure play major roles in the progression of this disease in patients.

Keywords: Prognostic factors, sepsis, sepsis progression, septic shock

How to cite this article:
Roham M, Abbaszadeh A, Zendehdel A, Momeni M, Mirzae N, Gholami M. Prognostic factors of sepsis rapid progression in patients admitted to Intensive Care Unit. Ann Trop Med Public Health 2017;10:1770-3

How to cite this URL:
Roham M, Abbaszadeh A, Zendehdel A, Momeni M, Mirzae N, Gholami M. Prognostic factors of sepsis rapid progression in patients admitted to Intensive Care Unit. Ann Trop Med Public Health [serial online] 2017 [cited 2018 Aug 18];10:1770-3. Available from: http://www.atmph.org/text.asp?2017/10/6/1770/222718



   Introduction Top


Sepsis, severe sepsis, and septic shock are terms used to describe the systemic response to an infection.[1],[2] Sepsis can be limited or developed toward septic shock or severe sepsis.[3]Sepsis is one of the syndromes that can have a high rate of mortality when it progresses toward septic shock or severe sepsis. In the process of disease, if the patient's blood pressure drops and develops tissue hypoperfusion or dysfunction of distant organs from the site of infection, severe sepsis is referred to him/her; and if the patient needs drugs for increasing blood pressure, he/she is in the stage of septic shock. The mortality caused from septic shock or severe sepsis is about 30%–50%.[4] Prognosis depends on factors such as underlying disease.[5] In addition, the type of microorganism that caused infection [6] as well as interleukin-6(IL-6) or IL-10 compared to tumor necrosis factor-alpha(TNF-alpha) is associated with the mortality of patients.[6]In studies conducted on critically ill patients in Intensive Care Unit(ICU), 25% of them at the time of admission to ICU and 13% after admission developed sepsis.[7]Factors affecting the prognosis of patients, who entered the phases of septic shock or severe sepsis, are somewhat known;[8] however, those which cause rapid progression of sepsis to septic shock or severe sepsis are still unknown.[9] Due to the high mortality of septic shock and severe sepsis, there is an urgent need for rapid and accurate prognosis of patients who are in danger of progression of this disease into stages of septic shock or severe sepsis. Although, at the moment, there are obstacles in the way of accurate prognosis of this disease in patients who are at risk of developing advanced diseases and death, this is more pronounced in patients who do not have severe diseases in their initial diagnosis. One of the strengths of this study was that only those patients whose infection was confirmed by positive cultures were enrolled in the study. The study was conducted on patients admitted to ICU, while most previous studies were performed in patients presenting to the emergency department. The purpose of this study was to investigate the effective factors on rapid progression of sepsis toward septic shock or severe sepsis.


   Materials and Methods Top


This is a retrospective cross-sectional and single-center study which included patients>12years old admitted to Shahid Motahari Hospital. This study examined patients admitted to ICU for 18months from October 2013 to March 2014 and included those with sepsis based on the diagnosis of ID specialist. These patients were diagnosed with a known infection and also showed two or more symptoms of systemic inflammatory response system(SIRS), which includes>20 breaths per minute, heart rate>90min, white blood cells>12,000cells per μL (microliter) or<4000, and finally, bandemia>10% and body temperature>38°C or<36°C. Patients who have had organ dysfunction at baseline were excluded from the study.Eventually, we investigated those patients whose progression of disease developed toward septic shock or severe sepsis and death within 72 h.

Severe sepsis in patients shows signs of failure in different organs. These patients were those whose urine output was<0.5ml per body weight per hour, mean arterial pressure(MAP) <65mmHg, systolic blood pressure<90mmHg, platelet count<80,000, or metabolic acidosis.

Septic shock refers to patients who, despite adequate fluid intake, had low blood pressure or needed vasopressor drugs. Rapid progression of sepsis is when patient develops septic shock or severe sepsis within 72h. Variables which were examined and analyzed are recorded in [Table1].
Table 1: Variables in patients

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Statistical analysis

Data was analyzed using SPSS software version 16 (SPSS Inc., Chicago, Illinois, USA). Statistical tests T, K–S, and Mann–Whitney U were used to verify information and statistical analysis.


   Results Top


We included 230patients with sepsis who were over12years. The most common sites of involvement in these patients were skin, bloodstream, lungs, and urinary tract(52%, 20%, 8%, and 3%, respectively), and the most common isolated microorganisms include Pseudomonas, Acintobacter, Klebsiella, and Staphylococcusaureus (60%, 22%, 8%, and 5%, respectively). Of these, 84patients developed septic shock and severe sepsis in<72h.

Effective factors in the progression of their disease were old age, high temperature, female sex, vascular catheter-related infections, low albumin, and diastolic pressure <52.

As indicated in [Table 2], other factors including diabetes, coronary heart disease, chronic kidney disease, chronic obstructive pulmonary disease or asthma, cancers, immunodeficiency, alcohol consumption and platelet level did not have significant impacts on rapid progress of sepsis towards septic shock and severe sepsis.
Table 2: Variables and their relationship with rapid progression of disease in patients with sepsis

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Rapid progression to sepsis shock had a high mortality within 30days(11.1 odds compared to 4.1).

Eighty percent of the patients with identified pathogen infections, received the required antibiotic within 24 h. However, there was no significant difference with regard to antibiotic consumption between the two groups of patients with septic shock and severe sepsis and patients whose disease was controlled (79% compared to 83%).

There was no death report of patients with septic shock and severe sepsis within 72h.


   Discussion Top


Septic shock and severe sepsis have a high chance of mortality.[10] This fact proves the importance of faster diagnosis of this disease in patients who are in danger of rapid progression of sepsis [9] and also faster implementation and treatment based on the defined protocols. These interventions include starting the treatment with antibiotics immediately, determining the origins of antibiotics and infection control, and finally quick recovery of patients. In our study, we tried to identify the important factors associated with sepsis progress toward septic shock and severe sepsis to improve the process of treatment of these patients with an accurate diagnosis. In our survey, in every three patients with sepsis, one of them developed severe sepsis or septic shock; however, in other studies, it was 12%–26%.[11],[12],[13]The probable reason is that we only studied patients whose infection was diagnosed. Finally, based on our results, we found that albumin<3.5 g/dL and diastolic pressure<52 mmHg are independent factors related to rapid progression toward septic shock, severe sepsis, or organ dysfunction.

Albumin is a marker of nutrition, but related factors to hypoalbuminemia in hospitalized patients are multiple. Two important factors causing hypoalbuminemia in patients with sepsis are decreased production of liver and loss of albumin through capillaries two times more than the normal range in patients with sepsis [14] and three times more in patients with septic shock.[15] This shows that measurement of cardiac vascular of albumin plays an important role in the progression of sepsis. Moreover, there is a significant relationship between low albumin and high mortality in patients with sepsis.[15] Researchers showed that there was a direct relationship between the progression of disease with low diastolic pressure and low serum albumin in patients with sepsis.[9] Diastolic pressure<52 mmHg was yet another important factor in the progression of this disease in our study. Patients, at the beginning of their admission, may not have hypotension, and their MAP and systolic pressure may be normal; however, low diastolic pressure at the time of diagnosing sepsis is not possible and because of that patients may develop signs of progression.[9] Terregino et al. proved that the amount of nitric oxide and TNF-alpha has a positive association with the disease progression toward septic shock, severe sepsis, and death.[16] On the other hand, these cytokines as vasodilators may drop diastolic pressure just before systolic pressure or MAP drops.[16] According to our results, factors such as old age, sex(female), hyperthermia, and catheter infection cause rapid progression of sepsis to septic shock and severe sepsis. One of the symptoms of SIRS is hyperthermia, which is related to the development of sepsis to septic shock.[2] Early pair cases in sepsis are also related to increase in endogenous pyrogenic mediators and metabolism.[17],[18] Alberti et al., similar to our study, found a relationship between temperature>38.2°C in ICU patients with sepsis and the progress of disease.[19] Capp et al. revealed that there is a positive relationship between female sex and the disease progression.[13] The same result was concluded from our study in which female sex has a significant role in the progression of sepsis. In our study, there was no difference between the two groups of patients who received antibiotics within the first 24h of sepsis, although we need more studies to prove this relationship. Patients with central venous catheter infection developed more severe sepsis(53%). Garrouste et al. reported that septicemia caused poor prognosis and increased the risk of mortality.[20] Furthermore, in a study on hemodialysis patients, it was found that one-fourth of patients died because of sepsis with vascular origin.[21] One of the key strengths of our study was the inclusion of patients with diagnosed and confirmed infections. Our survey was a single-centered retrospective study; however, if it was a multicentered prospective one, it would certainly have better results.


   Conclusion Top


Taken together, it can be said that factors such as age, sex, low albumin, and low diastolic pressure play an important role in the progression of sepsis disease in patients admitted to ICU.

Acknowledgment

We thank Staffs of Medical Records Ward and ICU of Motahari Hospital, especially Mrs. Mokhtari whose collaboration helped us in the process of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Correspondence Address:
Abolfazl Abbaszadeh
Department of Geriatric Medicine, Ziyaiyan Hospital, Tehran University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_646_17

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