DEBATE Sepsis and chronic wounds: 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 wound RICHARD WHITE defined as ‘a systemic inflammatory response patients, age, perfusion, nutritional status, Scientific Editor, Wounds UK, Professor of syndrome (SIRS) initiated by infection’ 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 incidence 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 diabetes. 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 deaths 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 death 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 antibiotic 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 cytokines 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 bacteria 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 blood pressure <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 injuries 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 16 Wounds UK | Vol 11 | No 4 | 2015 DEBATE 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 cancers. 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 skin 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 infections, 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 prevalence/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.