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Sepsis and chronic : the extent of the issue and what we should we be aware of

CONTRIBUTORS Sepsis, once referred to as ‘septicaemia’ is (Mayr et al, 2014). Thus for RICHARD WHITE defined as ‘a systemic inflammatory response patients, age, perfusion, nutritional status, Scientific Editor, Wounds UK, Professor of syndrome (SIRS) initiated by ’ immune status, site and depth of wound, Tissue Viability, University of Worcester and Director of DDRC Wound Care, Plymouth (Kleinpell et al, 2013). It is one of the main and comorbidities amongst other factors causes of morbidity and mortality worldwide constitute infection risk. More than half of all STEVEN JEFFERY (SJ) with an annual of 60 per 100,000 severe sepsis cases occur in patients over 65 Consultant Plastic Surgeon, The Queen patients in the UK (Shahin et al, 2012) and years (Mayr et al, 2010) or those with . Elizabeth Hospital, Birmingham 300 per 100,000 in the USA (Angus et al, In this context it is obvious that aged patients 2001). This accounts for over 37,000 with pressure ulcers and double incontinence ALAN ELSTONE (AE) Vascular Nurse Specialist, Derriford Hospital, per annum according to the UK Sepsis Trust are ‘at risk’, as are patients with large body Plymouth, Devon (McPherson et al, 2013). It is estimated to surface area burns. These examples, to the be the third most common cause of experienced wound clinician, will be widely- KEITH CUTTING (KC) in the USA where the incidence has been known risk factors. Clinical Research Consultant, Hertfordshire, UK increasing by 8–13% annually over the past Sepsis, together with bacteraemia, is decade (Marik, 2014). According to Prucha recognised as a major hazard in patients with n 2013, the UK identified sepsis et al (2015), ‘sepsis is the most frequent cause chronic wounds (Brem et al, 2003), being management as an NHS clinical priority. of death in non-coronary intensive care reported variously in diabetic foot ulcers The literature strongly suggests that units. In the past ten years, progress has been (Sapico et al, 1982), pressure ulcers (Jaul, 2010; Isepsis is a massive problem for healthcare made in the early identification of septic Messer, 2010), and leg ulcers (Ebright, 2005). services throughout the world and, in those patients and in their treatment and these Every clinician involved in wound areas where robust statistics are available, improvements in support and therapy mean management should be aware of, and the disease burden is high and incidence that the mortality is gradually decreasing but recognise, sepsis and its potential for and mortality are increasing dramatically. it still remains unacceptably high’. morbidity and mortality. The simple Reasons given for this include In pathophysiological terms, sepsis is an criteria of hyperthermia, acutely altered resistance, increased bacterial virulence and immune-inflammatory condition in which mental state, increased heart rate, an aging population. The economic burden such as TNF-α and IL-1β mediate plus tachypnoea should be evident to all

is similarly high, making improvement in a systemic response to infection (Surbatovic healthcare professionals and alert them , diagnosis and care clinical priorities. Gaps in et al, 2013). One of the key events in the to the possibility of ongoing serious acute care delivery have been identified and there is development of sepsis is the activation of illness. The death rate from sepsis and its evidence of an opportunity for cost-effective immune cells by pathogenic or quality improvement. Those clinicians their products (e.g. cell wall components Table 1. Diagnostic features suggestive involved in wound management, whether and toxins). The clinical picture varies with of sepsis acute or chronic, have a major part to play. the degree of infection. Sepsis per se is the Diagnostic criteria Threshold Wounds of all aetiologies represent a risk for presence of the SIRS criteria of hyperthermia Fever >38.3°C the development of severe sepsis, defined (38.3°C), acutely altered mental state, heart Tachycardia >90/minute below. Appropriate and timely management rate >90 per minute, white cells <4 or >12 x Systolic <90 mmHg 9 of wound bioburden and infection is integral 10 per litre, plus tachypnoea >20 per minute Procalcitonin >0.5 ng/ml to the avoidance of morbidity due to sepsis. (Table 1). Severe sepsis and septic shock are Lymphocytopenia <4.0 or >12 x 109/l Whilst it is widely recognised that patients further complications with additional criteria Neurophil/lymphocyte >10 with burns, traumatic soft tissue and (Daniels, 2010). ratio surgical wounds can, and do, develop life- The risk factors for sepsis have been divided Thrombocytopenia <150 × 103 ul threatening infection (Johnston et al, 2013), into two groups: a) risk factors for infection, Lactate >2.0 mmol/l it is less so for most ‘chronic’ wound patients. and b) risk factors for organ dysfunction

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complications is far too high. To reduce this, with chronic wounds contribute to sepsis 2. Do you think that nurses, both hospital a change in clinical practice is essential. The both in the acute and primary care settings. and community, are sufficiently aware of modern, evidence-based requirements for We are seeing an increasing and ageing sepsis and its risks for wound patients? early and accurate diagnosis and appropriate population living with multi-morbidity such intervention are well-documented (Koh et as diabetes, obesity, compromised immune SJ: For every 6 hours delay in the diagnosis al, 2012; Martin, 2012; Schorr et al, 2014). systems and . These conditions of sepsis, survival decreases by 10%. Whilst we cannot be precise on the place such individuals at a higher risk of Therefore identifying sepsis early is critical. contribution of wounds in general to sepsis, developing infection and subsequent sepsis. Nurses are the front line troops in medicine, it is quite clear that any wound has the Individuals with conditions such as chronic and are best placed to flag up that a patient potential to lead to an increased clinical oedema or lymphoedema are at continued, is becoming unwell. Sadly evidence risk. As ever, early recognition, appropriate increased risk of cellulitis, which if not indicates that delayed recognition of sepsis referral and intervention are likely to reduce effectively diagnosed, treated and managed is common. Assessment of the patient in morbidity. Richard White can lead to an increased risk of sepsis. both primary/community settings and Clinical findings such as chronic leg ulcers on hospital wards consists of evaluating 1. To what extent do you feel that chronic and diabetic foot ulcers are the resultant physical signs and symptoms. Excessive wounds contribute to sepsis/SIRS in both manifestations of continuums of chronic systemic inflammatory response is one of the community and acute settings? underlying disease processes, where predominant mechanisms for SIRS. Scoring significant tissue damage and compromise systems may be used to predict who is likely SJ: Identifying the cause of the infection that have already occurred, and are therefore to develop severe sepsis and/or to help make has resulted in sepsis would allow that cause associated with insufficient healing and a diagnosis in people with sepsis or severe to be treated. Unfortunately, it is not always an increased risk of infection. Individuals sepsis. Any patient with a wound containing possible to identify the cause of the sepsis. with significant end stage, severe peripheral necrotic tissue is at risk of developing sepsis According to the Parliamentary and Health arterial disease (critical limb ischaemia) — this must be borne is mind every time you Service Ombudsman Annual Report (2013), are often unable to promote healing of see such a patient. the most common causes of severe sepsis their lower limb tissues with resultant are pneumonia, bowel perforation, urinary subsequent ulceration and tissue loss. The AE: Over the last decade or so, nurses have infection and severe infection. In the compromised blood flow to their lower been made more aware of the problems presence of a chronic wound, infection of extremities, means the ability to manage associated with , antibiotic that wound would have to be considered as an effective response to localised infection resistance with the increase in methicillin- a likely cause in any patient with systemic becomes less likely increasing the risk of resistant staphylococcus aureus (MRSA) sepsis. The extent of the size of pressure sepsis. and related bacterial infections and the sores are often greatly underestimated. Even problems which these issues can bring small ulcers can be extensively undermined, KC: The relationship between chronic to the various clinical settings and the resulting in a large amount of necrotic tissue wounds and sepsis has never been subjected implications for the patients that they are and a large surface area for the entry of to scrutiny in terms of /incidence caring for. Despite various tools to assist the bacteria. When, as is so often the case, the or audit so we can only rely on intuition to practitioner, there is still a way to go with patient has underlying comorbidities that assist in gauging the extent that chronic recognising and appropriately managing reduce their ability to resist infection, sepsis/ wounds contribute to the occurrence of chronic wounds which will always have SIRS is the outcome. sepsis in hospital and community settings. an increased bacterial load by their very In order to manage a healthcare challenge nature within the clinical setting. Routine AE: Sepsis can be triggered by an infection successfully it is vital that the size of the swabbing of chronic leg ulcers is costly and in any part of the body and these common problem is officially understood and often of little clinical value and can lead sites of infection are primarily the lungs, acknowledged. A confounding problem to inappropriate prescribing of antibiotic abdomen, pelvis, the urinary tract and in the UK is that, we have no idea of the therapy. We cannot just look at the wound the skin. Sepsis is a more common reason national prevalence of pressure ulcers so presented to us as clinicians, there is a for hospital admission than heart attack, how can we hope to understand the extent fundamental need to assess the individual and has a higher mortality (Parliamentary of the chronic wound/sepsis situation. Is as a whole and identify factors which could and Health Service Ombudsman, 2013). it time to seek information through the increase their clinical risk of sepsis. Sepsis There can be no question that patients Freedom of Information Act? can be difficult to recognise in the early

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stages (Peters and Cohen, 2013) and as guidelines were not designed to help involved in the treatment of sepsis. Blood nurses we are presented with individuals at clinicians recognise sepsis. They were cultures often return negative findings an ever increasing risk of developing sepsis, designed to establish whether patients were leaving the clinician with little option but so further continuing education needs to eligible to join clinical trials! Nevertheless, to prescribe broad-spectrum . occur at both local and national levels. We they are useful for clinicians in diagnosing Administering antibiotics that are not also need to highlight the importance of sepsis. Unfortunately some doctors specifically targeted increases the risk of prevention of sepsis within our daily clinical (particularly non-surgeons) ignore any bacterial selection for resistance. However, practice. Nurses involved in the specialist chronic wounds patients may have. They waiting for a positive blood culture before care of patients with both acute and chronic may not even take the dressings down! In prescribing antibiotics is not acceptable as wounds have a fundamental role to play in assessing a patient with sepsis, the whole mortality increase by 10% for every 6 hour highlighting the importance and danger of patient needs to be examined in order to find delay in prescribing. sepsis occurring in clinical practice. a cause. This includes taking down every dressing and examining every wound. 4. Does your department or Trust have KC: Nurses, both in the hospital and a comprehensive guideline for the community, should be aware of sepsis risks. AE: When you consider the figures recognition, diagnosis and management It has been pointed out that for wound presented as evidence before us — 37,000 of sepsis/SIRS? patients, age, perfusion, nutritional status, people in the UK dying as a result of sepsis immune status, site and depth of wound, each year (Parliamentary and Health SJ: Yes, we have very clear guidelines, and comorbidities constitute infection Service Ombudsman, 2013) — there is little including: risk. These factors should be included as doubt that there is a fundamental need to a) Recognition and assessment: components of ‘standard’ assessment and heighten the awareness of the recognition, symptoms, signs and investigations therefore cannot be considered obscure. diagnosis and treatment of patients with b) Life-threatening features Awareness of the risk of sepsis to wound sepsis with medical practitioners, in addition c) Initial management with a sepsis care care patients amongst ‘general’ nurses to the prevention in the first instance. It is bundle, including antibiotic treatment and should therefore not be below the radar probably high on the agenda for critical care fluid resuscitation and for those working in tissue viability practitioners but we need to ensure it has d) Subsequent management. there should be heightened awareness. In a heightened awareness and importance in Early identification of sepsis allows this context, it is important to note that a more generalist setting to promote early appropriate treatment to be started standards of care for sepsis are achieved intervention. The UK Sepsis Trust (2105) quickly. People with sepsis or suspected in only 20% of cases. This is despite advocates the use of the Sepsis six tool sepsis can deteriorate quickly, and internationally recognised guidelines being which recommends six urgent interventions appropriate monitoring can identify accepted by relevant professional bodies. with a diagnosis of sepsis: high flow oxygen, this deterioration and detect response blood cultures, broad spectrum antibiotics, to treatment. These guidelines provide 3. Do you think that doctors, intravenous fluid challenges, serum lactate a framework for current intensive care both hospital and community, are and haemoglobin levels and close, accurate management. Catecholamines remain sufficiently aware of sepsis and its risks urinary output monitoring. There is little the primary vasopressors used to treat for wound patients? question that the clinical signs of suspected hypotension during septic shock after IV sepsis should be seen as a clinical emergency. fluid resuscitation. In septic shock, the SJ: Clinicians often struggle to identify early Modern medicine and its achievements use of low-dose corticosteroids has been cases of sepsis that need urgent treatment clearly saves lives but with this comes an proposed as an adjunctive therapy to reduce to prevent progression to severe sepsis. increased risk of sepsis. mortality and improve shock reversal. Sepsis Consensus definitions for sepsis in the is a major cause of death in the intensive critically ill population couple criteria for KC: Doctors working in the hospital or care units, with a mortality rate of about SIRS with the documented presence of community setting should be acutely 30%. When severe sepsis resolves, recovery infection, following the guidelines from aware of the risk of sepsis in all patient is normally complete. In the event of death, the American College of Chest Physicians groups. However, and this also applies to the Coroner’s office needs to be informed. (ACCP), Society of Critical Care Medicine nurses, there are acknowledged difficulties (SCCM) and the European Society of with recognising sepsis through accurate AE: Our trust in line with many, has Intensive Care Medicine (ESICM). These diagnosis. There are also challenges a comprehensive guideline for the

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recognition, diagnosis and management AE: Sepsis leads to shock, multiple organ early intervention is key to success but we of sepsis. Again, like most there is a failure and death if not recognized early and also have to be aware of the dangers of over- very effective and vital infection control treated promptly. Individuals with wounds diagnosis, e.g. pseudosepsis. Wuk department. The problem for practitioners we have identified are already compromised both medical and nursing, is that we are and have a potential source of sepsis. Local References increasingly presented with a variety of wound care policies and assessment forms Angus DC, Linde-Zwirble WT, Lidicker I et al (2001) Epidemiology of severe sepsis in the United States: analysis of information, best practice guidelines, used in clinical practice need to highlight the incidence. Crit Care Med 29(7): 1303–10 policies and these are continually changing, increased risk of potential sepsis within this Brem H, Tomic-Canic M, Tarnovskaya A et al (2003) Healing of becoming increasingly complex and cohort of patients, in order for practitioners elderly patients with diabetic foot ulcers, venous stasis ulcers, evolving in the light of clinical research to be increasingly vigilant regarding the risk and pressure ulcers. Surg Technol Int 11: 161–7 Daniels R (2010) Identifying the patient with sepsis. In: Daniels and evidence, that it becomes increasing of developing sepsis. Patients at increased R, Nutbeam T. ABC of Sepsis. Wiley-Blackwell/BMJ Books, challenging for clinicians to keep up to risk of sepsis need to be identified and closely Oxford: 10–4 date, to find the time to access and read this monitored and action swiftly taken if sepsis is Ebright JR (2005) Microbiology of chronic leg and pressure ulcers: clinical significance and implications for treatment. information and prioritise the relevance of suspected. Practitioners need to manage the Nurs Clin North Am 40(2): 207–16 the information, in addition to attempting bioburden effectively within chronic wounds Jaul E (2010) Assessment and management of pressure ulcers in to apply it in practice. We have to see sepsis and not rely on anti-bacterial dressings to the elderly: current strategies. Drugs Aging 27(4): 311–25 prevention and management as a clinical prevent infection developing. Johnston AM, Easby D, Ewington I (2013) Sepsis management in the deployed field hospital. J R Army Med Corps 159(3): priority. From a national perspective, there is 175–80 continuing need to advance the sepsis Kleinpell R, Aitken L, Schorr CA (2013) Implications of the new agenda and to continue to heighten the international sepsis guidelines for nursing care. Am J Crit Care 5. What steps would you take a) locally, 22(3): 212–22 and b) nationally to reduce the incidence awareness of sepsis with all levels of Koh GC, Peacock SJ, van der Poll T, Wiersinga WJ (2012) The of sepsis/SIRS in wound patients? clinicians, through effective communication impact of diabetes on the pathogenesis of sepsis. Eur J Clin and education. This will not only save lives Microbiol Infect Dis; 31(4): 379–88 Marik PE (2014) Definition of sepsis: not quite time to dump SJ: Locally, we are working towards but fundamentally improve the outcomes SIRS? Crit Care Med 130(3): 706–8 developing better aids to diagnose sepsis for individuals presenting with clinical Martin GS (2012) Sepsis, severe sepsis and septic shock: changes earlier. The use of standard markers of sepsis. The National Institute for Health in incidence, pathogens and outcomes. Expert Rev Anti Infect Ther 10(6): 701–6 infection can be misleading in sepsis as and Care Excellence (NICE) are currently Mayr FB, Yende S, Linde-Zwirble WT et al (2010) Infection apparently normal test results (such as for developing guidance on the recognition, rate and organ dysfunction risk as explanation for racial white cell count) may be associated with diagnosis and management of sepsis and differences in severe sepsis.JAMA 303(24): 2495–503 an overwhelmed . Blood this is due for publication in July 2016. There Mayr FB, Yende S, Angus DC (2014) Epidemiology of severe sepsis. Virulence. 5(1): 4-11 culture, although helpful, is of limited value needs to be clear, uniform, succinct and Messer MS (2010) Pressure risk in ancillary services due to frequent absence of bacteraemia accessible guidance to increase awareness, patients. J Wound Ostomy Continence Nurs 37(2): 153–8 in many cases of obvious life threatening increase early identification and improve Parliamentary and Health Service Ombudsman (2013) Time sepsis. function is thought to be the management of patients with sepsis. to Act: Severe Sepsis: Rapid Diagnosis and Treatment Saves Lives. Available at: http://www.ombudsman.org.uk/__ data/ important in the development of sepsis and This will in turn reduce the variation seen in assets/pdf_file/0004/22666/FINAL_Sepsis_Report_ web. work is currently on-going in Birmingham clinical practice and improve outcomes for pdf (accessed 21.10.2015) to elucidate this further. all concerned, and possibly prevent missed Peters J, Cohen J (2013) Sepsis. Medicine 41 (11): 667–9 Prucha M, Bellingan G, Zazula R (2015) Sepsis biomarkers. Clin Nationally, I am looking forward to July opportunities to save lives. Chim Acta 2; 440: 97–103 2016 when the NICE guidelines: ‘Sepsis: the Sapico FL, Bessman AN, Canawati HN (1982) Bacteremia in recognition, diagnosis and management of KC: There has to be widespread and diabetic patients with infected lower extremities. Diabetes Care 5(2):101–4 severe sepsis’ are due to be published. effective education amongst clinical and Schorr CA, Zanotti S, Dellinger RP (2014) Severe sepsis and To prevent infection developing, I hope lay communities to raise awareness of the septic shock: management and performance improvement. that better use of the various risk of sepsis and in its recognition; like the Virulence. 5(1): 190–9 techniques now available, and the use of very successful national campaign to raise Shahin J, Harrison DA, Rowan KM (2012) Relation between volume and outcome for patients with severe sepsis in United topical antimicrobials, e.g. prontosan will awareness of stroke and the importance of Kingdom: retrospective cohort study. BMJ 344: e3394 prevent and manage wound and obtaining early intervention. It is important Surbatovic M, Veljovic M, Jevdic J et al (2013) reduce the progression from contamination to note that annual deaths from lung Immunoinflammatoryresponse in critically ill patients: severe sepsis and/or trauma. Mediators Inflamm362793 to colonisation to local infection and then in the UK are broadly similar to the sepsis UK Sepsis Trust (2015) Clinical Tools. Available at: http:// systemic infection. mortality rate. With sepsis and wounds sepsistrust.org/clinical-toolkit/ (accessed 21.10.2015)

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