May/June 2013

Sepsis Requires Urgent Attention

By Jessica Girdwain
Aging Well
Vol. 6 No. 3 P. 26

A significant and increasing threat to older adults, sepsis can go undetected or be misdiagnosed. And as patients age, they are more susceptible not only to this potentially deadly condition but also to the chronic diseases with which sepsis is associated.

A new groundbreaking study published in PLOS One analyzed the medical records of more than 30,000 patients and concluded that not only is sepsis associated with older age, but a history of chronic disease also influences a patient’s risk.

The research showed, for example, that suffering from chronic lung disease increased the likelihood of developing sepsis by 143%, from kidney disease by 99%, from heart attack by 79%, from stroke by 67%, and from hypertension by 49%. The risk of sepsis increased further if patients had other chronic medical conditions.

The study findings provide more information about a disease that isn’t well known and is often overlooked, even among the health care community.

Societal Burden
“Sepsis is not a sexy term,” says Henry E. Wang, MD, MPH, an associate professor and the vice chairman for research at the University of Alabama at Birmingham and a researcher on the new sepsis study. “People don’t understand what it means. They know about heart attack, stroke, diabetes but not sepsis.”

Despite the lack of public knowledge and awareness regarding sepsis, the effects of the condition are significant. “The societal burden of sepsis is incredibly large,” Wang says, referring not only to the number of sepsis patients hospitalized each year (roughly 750,000) but the health care costs associated with the disease: $17 billion annually, a figure that exceeds myocardial infarction, according to the National Institute of General Medical Sciences. Additionally, about 200,000 people die annually from sepsis.

Practitioners generally are familiar with sepsis and its symptoms, but it’s still a frequently missed diagnosis. “Sepsis flies under the radar in patients. That’s why I call it the ‘ninja disease’—it’s everywhere, but we don’t know it’s there,” Wang says.

“Sepsis is the most common killer in medical intensive care units. More people die from it every year than lung and breast cancer and stroke combined,” explains Mitchell Levy, MD, a professor of medicine at Brown University and an authority on sepsis.

Subtle Symptoms
Sepsis begins as an infection that triggers systemic inflammation that can lead to organ failure, shock, and death. As the older adult population continues to grow, sepsis presents an even greater threat to members of this age group. Wang notes that the increase in sepsis cases may be attributed, in part, to the fact that physicians are more attuned to its symptoms and subsequently are making earlier diagnoses. “We are now able to identify sepsis better, which will automatically increase the rates we see,” he says.

Physicians treating older adults must be alert to the first signs of an infection and recognize its extent. For example, Wang notes that an older patient with sepsis may lose 3 L of fluid from the shock of the condition but can maintain a normal blood pressure until suddenly it bottoms out. The subtlety of sepsis symptoms requires physicians to pay close attention to a patient’s vital signs to detect their presence. Additionally, early symptoms of sepsis, such as confusion or weakness, often are vague and can even appear nearly normal in an elderly patient, preventing the connection to sepsis from being obvious.

When considering a sepsis diagnosis, physicians should be aware of symptoms such as a high heart or breathing rate, a high white blood cell count, and fever, according to Levy. Since symptoms can be mistaken for other conditions, health care practitioners should be vigilant regarding small infections accompanied by a fever that spikes rapidly as well as shaking, chills, and a racing heart.

Chronic Medical Conditions Can Provide Clues
Wang’s research is particularly important because it supports clinicians’ ability to better predict which older adults may be more vulnerable to sepsis than others based on chronic conditions. It highlights the significance of having a personal history of chronic medical conditions, such as lung or kidney disease, and an increased susceptibility to developing sepsis.

Likewise, diabetes may be linked to a future diagnosis of sepsis because diabetes weakens a patient’s body, making it more difficult to adequately fend off infection. “For every comorbidity a patient has, their body’s ability to respond to stress is much more difficult,” Wang says. “Let’s say someone has already suffered a heart attack. The heart is already damaged and the body will have a difficult time responding to the stress of infection, making it more likely they’ll develop a full-blown response to sepsis.”

Location, Location, Location
Wang’s earlier research, published in 2010 in the International Journal of Health Geographics, examined the regional variations of sepsis via data from the National Center for Health Statistics. While sepsis death was found to occur at a rate of 65.5 per 100,000 people, some areas of the United States—particularly what is known as the Sepsis Belt, which extends from the southeastern to mid-Atlantic states, including Mississippi, Alabama, Georgia, Tennessee, North Carolina, Virginia, Maryland, Delaware, and New Jersey—reported rates of sepsis mortality that were twofold higher than states outside the belt.

While researchers haven’t pinpointed the underlying cause of the high rates in the Sepsis Belt, they could be attributed to the regional differences in sepsis treatment or health habits and diets. Specifically, obesity is a risk factor for sepsis, and there’s a correlation between geographically high rates of obesity and sepsis. Wang’s newest research also indicates that the Sepsis Belt closely mirrors the Stroke Belt, making the case that chronic disease is linked to a patient’s risk.

Researchers also are examining the racial disparity related to sepsis incidence because the condition is more prevalent in white vs. black Americans. This may reflect heredity, health care, or lifestyle choices, but until researchers conduct further studies, there are no definitive answers.

Proactive Approach
What should physicians do to keep older patients informed about sepsis? First, it’s important to maintain a cautious dialogue with older patients about what sepsis is and the warning signs. “Patients should be informed but also be realistic. Just because they have a fever and shortness of breath does not mean that they have to run to the emergency room,” Levy says.

Advise patients to use common sense as their guide. Before patients leave the office following an exam, inform them that if they’re not feeling well or their condition fails to improve—particularly if they develop a rising fever and shaking chills—to seek medical attention.

Sepsis survival rates range from 50% to 80%, Levy says. Patient response to treatment largely depends on the stage of sepsis at the time of diagnosis and where the infection originates. Skin or bladder infections, for instance, have good survival rates, whereas pneumonia or abdominal infections have lower survival rates.

The Surviving Sepsis Campaign (www.survivingsepsis.org), a website maintained by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, can provide helpful information for sepsis patients and their families or caregivers.

— Jessica Girdwain is a Chicago-based freelance writer who has contributed health-related articles to several national magazines.