Q&A: World Sepsis Day

Konrad Reinhart
Konrad Reinhart

According to WHO, sepsis is estimated to affect more than 30 million people around the world annually, causing up to 6 million deaths, with the burden likely highest in low- and middle-income countries.

In 2012, the Global Sepsis Alliance — a non-profit organization — began World Sepsis Day to raise awareness of proper prevention, diagnosis and treatment of the potentially deadly condition to reduce global sepsis deaths by 20% by 2020. The day is marked each year on Sept. 13, in the middle of Sepsis Awareness Month.

Infectious Disease News spoke with Konrad Reinhart, MD, chair of the Global Sepsis Alliance, about factors contributing to the global rise of sepsis, its relationship with antimicrobial resistance and what can be done to reduce global sepsis deaths. – by Marley Ghizzone

What is contributing to the global rise of sepsis?

There are two reasons why the incidence of sepsis is increasing. One reason is simply that we’re doing a better job of tracking sepsis incidence so that we can do better as a medical system to address it. But the other reason is that there are more infections, and without proper intervention, some infections can lead to sepsis.

Although the relationship between infection and sepsis has been fully understood for many years, the medical system was not doing a good job of accounting for cases of sepsis. Because the hospitals improved the coding standards over the last 5 years, we’ve seen an increase in sepsis cases. This means these cases were there before, but owing to lack of awareness of sepsis, only the underlying infection that caused it was documented and coded according to the International Classification of Diseases system (ICD). This is the main reason for the apparent annual increases in the incidence of sepsis of between 5% and 10%. On the other hand, the true number of sepsis cases is more than twice as high as was presumed on the basis of hospital discharge data for billing and the documentation in the ICD. This is suggested by studies from the United States and Sweden that looked for the symptoms and criteria for sepsis directly in the patient’s health records. This means that in these countries, annually, between 500 and 700 per 100,000 population have sepsis. The current estimates for the incidence of sepsis in high-income countries ranged between 300 and 350 per 100,000 population.

Likewise, there are also objective reasons for an increase in sepsis rates, such as the higher susceptibility of the elderly, who not only experience an increasing number of chronic diseases, such as of the lung, liver, kidney and diabetes but also are subjected to invasive surgical and medical interventions and medications that impair the immune system. For example, this is the case for many medications that are widely used for the treatment of cancer and rheumatic diseases and major surgical interventions. Also, several lifesaving interventions that are necessary in the ICUs, such as mechanical ventilation, central lines and dialysis, bear a risk for infections and, thus, sepsis.

What is the relationship between sepsis and antimicrobial resistance?

Antimicrobials are the only cure for sepsis, although about 30% of patients may require surgery in addition to antimicrobials to control the source of the infection. For example, if you have gallstones and kidney stones with an infected gallbladder or kidney or an infected heart valve or hip prosthesis, you will need to undergo surgery.

As antimicrobials become less effective, we may increasingly fail to effectively treat infections and prevent their progress to sepsis, and if we have patients whose sepsis is caused by multidrug-resistant pathogens, the chance of survival becomes even worse.

What actions must be taken to reduce global sepsis deaths by 20% by 2020?

Physicians need to focus on at least three areas. One area is to prevent those infections that are avoidable by vaccination. Global vaccination rates, even in the developed world, vary considerably. Most high-income countries have achieved good vaccination rates for children in the range of 80% to 90%. However, in adults for example, the vaccination rates against seasonal influenza and pneumococci are lower and vary a lot, whereas in countries like the U.S., vaccination rates range from 50% to 70%. In Germany for example, the vaccination rate for seasonal influenza and pneumococci is in the range of only 20% or 30%. This may contribute to the higher sepsis mortality rates that we observe in Germany compared with those in Australia, the U.S. and the United Kingdom. But improving vaccination rates is only one way to prevent sepsis.

The other two important areas are promoting better hygiene practices by hospitals or heath care providers; and treating infections as early as possible to prevent progression to sepsis.

How is the “I’m a resistance fighter” campaign raising awareness of sepsis and how can others get involved?

The Global Sepsis Alliance’s role in the “resistance fighter” campaign is to strongly suggest to many experts the need to work and collaborate globally and to improve antimicrobial stewardship to ensure that those who need effective antimicrobials receive it in due time, because sepsis is an emergency and every delay in antimicrobial treatment increases sepsis mortality by 2% per hour. Teaching and good stewardship also mean discontinuing antimicrobials when they are no longer required because this contributes to antimicrobial resistance. That is why the global action plan against antimicrobial resistance and the global fight against sepsis need to be aligned much more effectively. Both campaigns will benefit from each other, because they not only have the same goals, which is to save lives, but also help society. Health care authorities and caregivers understand what is at stake without appropriate use and the preservation of effective antimicrobials.

I joined the “I’m a resistance fighter” campaign created by Becton, Dickinson and Company because sepsis awareness and education is so critical. Collectively, we are driving global, concentrated efforts to raise awareness of the need to combat antimicrobial resistance and the necessary actions being taken.

The main tool that we have at our hands is effective antimicrobials. When more and more pathogens become resistant to the currently available antimicrobials, the problem increases the likelihood that patients will die. Diagnostics also play a role in helping clinicians identify the source of infection and to know the antimicrobials that are most effective in treating it and finally to administer and to discontinue them as early as possible.

We need to do everything to fight antimicrobial resistance. By getting involved, we aim to encourage others to share their stories of survival, remembrance or commitment, and to inspire others to act because we all need to be resistance fighters. (To learn more about the campaign and share a story, visit www.antimicrobialresistancefighters.org.)

What do clinicians need to know about sepsis prevention, diagnosis and treatment?

Clinicians need to know that sepsis can be prevented by preventing infections through [better hygiene] and in part by vaccination, and that the diagnosis and treatment must be made timely and appropriately because it is an emergency. That is why all health care workers and physicians need to know the earliest symptoms of sepsis, which are often fever and shivering, mental alterations, rapid breathing, hypotension and often the patient feels extremely sick as never before. Because 80% of sepsis cases begin in the community, ED physicians and health care workers need to be familiar with the early signs of sepsis and rule out that a patient has sepsis and act fast if the suspicion for sepsis is high. This knowledge must also be learned by the nurses, because 20% to 30% of patients develop sepsis in the hospital and often on regular wards. Also, not all nurses are adequately trained to expect or know the early signs of sepsis and physicians need to educate nurses in recognizing deteriorating patients. In some countries, health care workers are consistently taught how to appropriately use early warning scores for deteriorating patients on the national and hospital level and have implemented rapid response teams to act on these patients — most of whom have sepsis — as soon as possible. This must become a standard of care in all parts of the world.

Disclosures: Reinhart is an unpaid chair of the Global Sepsis Alliance and has advised some pharmaceutical and diagnostic companies in the development of novel diagnostic and therapeutic tools.

Konrad Reinhart
Konrad Reinhart

According to WHO, sepsis is estimated to affect more than 30 million people around the world annually, causing up to 6 million deaths, with the burden likely highest in low- and middle-income countries.

In 2012, the Global Sepsis Alliance — a non-profit organization — began World Sepsis Day to raise awareness of proper prevention, diagnosis and treatment of the potentially deadly condition to reduce global sepsis deaths by 20% by 2020. The day is marked each year on Sept. 13, in the middle of Sepsis Awareness Month.

Infectious Disease News spoke with Konrad Reinhart, MD, chair of the Global Sepsis Alliance, about factors contributing to the global rise of sepsis, its relationship with antimicrobial resistance and what can be done to reduce global sepsis deaths. – by Marley Ghizzone

What is contributing to the global rise of sepsis?

There are two reasons why the incidence of sepsis is increasing. One reason is simply that we’re doing a better job of tracking sepsis incidence so that we can do better as a medical system to address it. But the other reason is that there are more infections, and without proper intervention, some infections can lead to sepsis.

Although the relationship between infection and sepsis has been fully understood for many years, the medical system was not doing a good job of accounting for cases of sepsis. Because the hospitals improved the coding standards over the last 5 years, we’ve seen an increase in sepsis cases. This means these cases were there before, but owing to lack of awareness of sepsis, only the underlying infection that caused it was documented and coded according to the International Classification of Diseases system (ICD). This is the main reason for the apparent annual increases in the incidence of sepsis of between 5% and 10%. On the other hand, the true number of sepsis cases is more than twice as high as was presumed on the basis of hospital discharge data for billing and the documentation in the ICD. This is suggested by studies from the United States and Sweden that looked for the symptoms and criteria for sepsis directly in the patient’s health records. This means that in these countries, annually, between 500 and 700 per 100,000 population have sepsis. The current estimates for the incidence of sepsis in high-income countries ranged between 300 and 350 per 100,000 population.

Likewise, there are also objective reasons for an increase in sepsis rates, such as the higher susceptibility of the elderly, who not only experience an increasing number of chronic diseases, such as of the lung, liver, kidney and diabetes but also are subjected to invasive surgical and medical interventions and medications that impair the immune system. For example, this is the case for many medications that are widely used for the treatment of cancer and rheumatic diseases and major surgical interventions. Also, several lifesaving interventions that are necessary in the ICUs, such as mechanical ventilation, central lines and dialysis, bear a risk for infections and, thus, sepsis.

What is the relationship between sepsis and antimicrobial resistance?

Antimicrobials are the only cure for sepsis, although about 30% of patients may require surgery in addition to antimicrobials to control the source of the infection. For example, if you have gallstones and kidney stones with an infected gallbladder or kidney or an infected heart valve or hip prosthesis, you will need to undergo surgery.

As antimicrobials become less effective, we may increasingly fail to effectively treat infections and prevent their progress to sepsis, and if we have patients whose sepsis is caused by multidrug-resistant pathogens, the chance of survival becomes even worse.

What actions must be taken to reduce global sepsis deaths by 20% by 2020?

Physicians need to focus on at least three areas. One area is to prevent those infections that are avoidable by vaccination. Global vaccination rates, even in the developed world, vary considerably. Most high-income countries have achieved good vaccination rates for children in the range of 80% to 90%. However, in adults for example, the vaccination rates against seasonal influenza and pneumococci are lower and vary a lot, whereas in countries like the U.S., vaccination rates range from 50% to 70%. In Germany for example, the vaccination rate for seasonal influenza and pneumococci is in the range of only 20% or 30%. This may contribute to the higher sepsis mortality rates that we observe in Germany compared with those in Australia, the U.S. and the United Kingdom. But improving vaccination rates is only one way to prevent sepsis.

The other two important areas are promoting better hygiene practices by hospitals or heath care providers; and treating infections as early as possible to prevent progression to sepsis.

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How is the “I’m a resistance fighter” campaign raising awareness of sepsis and how can others get involved?

The Global Sepsis Alliance’s role in the “resistance fighter” campaign is to strongly suggest to many experts the need to work and collaborate globally and to improve antimicrobial stewardship to ensure that those who need effective antimicrobials receive it in due time, because sepsis is an emergency and every delay in antimicrobial treatment increases sepsis mortality by 2% per hour. Teaching and good stewardship also mean discontinuing antimicrobials when they are no longer required because this contributes to antimicrobial resistance. That is why the global action plan against antimicrobial resistance and the global fight against sepsis need to be aligned much more effectively. Both campaigns will benefit from each other, because they not only have the same goals, which is to save lives, but also help society. Health care authorities and caregivers understand what is at stake without appropriate use and the preservation of effective antimicrobials.

I joined the “I’m a resistance fighter” campaign created by Becton, Dickinson and Company because sepsis awareness and education is so critical. Collectively, we are driving global, concentrated efforts to raise awareness of the need to combat antimicrobial resistance and the necessary actions being taken.

The main tool that we have at our hands is effective antimicrobials. When more and more pathogens become resistant to the currently available antimicrobials, the problem increases the likelihood that patients will die. Diagnostics also play a role in helping clinicians identify the source of infection and to know the antimicrobials that are most effective in treating it and finally to administer and to discontinue them as early as possible.

We need to do everything to fight antimicrobial resistance. By getting involved, we aim to encourage others to share their stories of survival, remembrance or commitment, and to inspire others to act because we all need to be resistance fighters. (To learn more about the campaign and share a story, visit www.antimicrobialresistancefighters.org.)

What do clinicians need to know about sepsis prevention, diagnosis and treatment?

Clinicians need to know that sepsis can be prevented by preventing infections through [better hygiene] and in part by vaccination, and that the diagnosis and treatment must be made timely and appropriately because it is an emergency. That is why all health care workers and physicians need to know the earliest symptoms of sepsis, which are often fever and shivering, mental alterations, rapid breathing, hypotension and often the patient feels extremely sick as never before. Because 80% of sepsis cases begin in the community, ED physicians and health care workers need to be familiar with the early signs of sepsis and rule out that a patient has sepsis and act fast if the suspicion for sepsis is high. This knowledge must also be learned by the nurses, because 20% to 30% of patients develop sepsis in the hospital and often on regular wards. Also, not all nurses are adequately trained to expect or know the early signs of sepsis and physicians need to educate nurses in recognizing deteriorating patients. In some countries, health care workers are consistently taught how to appropriately use early warning scores for deteriorating patients on the national and hospital level and have implemented rapid response teams to act on these patients — most of whom have sepsis — as soon as possible. This must become a standard of care in all parts of the world.

Disclosures: Reinhart is an unpaid chair of the Global Sepsis Alliance and has advised some pharmaceutical and diagnostic companies in the development of novel diagnostic and therapeutic tools.