Septicemia is the presence of microbes or their toxins in the blood. It refers to the active multiplication of bacteria in the bloodstream usually with the production of severe systemic symptoms such as fever and hypotension.
Bacteraemia is the presence of bacteria in the blood, as evidenced by positive blood cultures.
Septicemia has extremely high mortality and demand immediate attention.
Sepsis is a clinical term used to describe symptomatic bacteremia, with or without organ
dysfunction.
Sustained bacteremia, in contrast to transient bacteremia, may result in a sustained febrile
response that may be associated with organ dysfunction.
Pathophysiology
• The pathophysiology of sepsis is complex and results from the effects of circulating
bacterial products, mediated by cytokine release, caused by sustained bacteremia.
• Cytokines, previously termed endotoxins are responsible for the clinically observable
effects of the bacteremia in the host.
• Impaired pulmonary, hepatic, or renal function may result from excessive cytokine
release during the septic process.
Epidemiology
• Sepsis is a common cause of mortality and morbidity worldwide.
• The prognosis of sepsis depends on the underlying status and host defenses, prompt and
adequate surgical drainage of abscesses, relief of any obstruction of the intestinal or
urinary tract, and appropriate and early empiric antimicrobial therapy with the drug
spectrum appropriate to the presumed septic source.
• Sepsis does not appear to have a racial or sex predisposition.
• Elderly men are more likely to develop urosepsis due to benign urinary tract obstruction
caused by prostatic hypertrophy.
Etiology
• Sepsis or septic shock may be associated with the direct introduction of microbes into the
bloodstream via intravenous infusion (e.g., intravenous line, other device-associated
infections).
• An the intra-abdominal or pelvic structure may be perforated, compromised, or ruptured.
• Bacteremia due to bacteriuria (urosepsis) may complicate cystitis in compromised hosts
• Intrarenal infection (pyelonephritis), renal abscess (intrarenal or extrarenal), acute
prostatitis, or prostatic abscess may cause urosepsis in immunocompetent hosts.
• Sepsis maybe caused by an overwhelming pneumococcal infection in patients with impaired
or absent splenic function.
• Meningococcemia from a respiratory source may also result in sepsis, with or without
associated meningitis.
Causes of Septicaemia in a Previously Healthy Adult
Site of Origin Usual Pathogen(s)
Skin Staphylococcal aureus and other gram
positive cocci
Urinary Tract Escherichia coli and other aerobic gram
negative rods
Respiratory tract Streptococcal pneumoniae
Gallbladder or bowel Streptococcus faecalis, E. coli, other gram
negative rods and Bacteroides fragilis
Pelvic organs Neisseria gonorrhea and anaerobes
Clinical Problem Usual Pathogens
Urinary catheter Escherichia coli, Klebsiella spp, Proteus spp.
Intravenous catheter Staphylococcus aureus and Staphylococcus
epidermidis, Klebsiella spp, Pseudomonas
spp, Candida albicans
Peritoneal catheter Staphylococcus epidermis
Post -surgery: wound infection Staphylococcus aureus, E. coli, anerobes
(depending on the site)
Burns Gram positive cocci, Pseudomonas spp,
Candida albicans
Immunocompromised patient Any of the above
Clinical Features and Differential Diagnosis of Septicemia
Cardinal Features of Severe Septicemia
• Fever
• Rigors
• Hypotension
Less Specific Features
• Headache
• Lethargy
• Nervousness
• Change in conscious level
• Pulmonary edema and adult respiratory distress syndrome
• Disseminated intravascular coagulation (DIC)
Differential Diagnoses
Clinical Conditions Associated with Sepsis and its Mimics
Associated with Sepsis (Fevers > 39ºC) Associated with Sepsis (Fevers < 39ºC)
Gastrointestinal tract source
• Liver, Gallbladder, Colon Abscess
• Intestinal obstruction instrumentation
Gastrointestinal tract source
• Esophagitis, Gastritis, Pancreatitis
• Small bowel disorders
• GI bleeding
Genitourinary tract source
• Pyelonephritis
• Intra/perinephric abscess, Renal calculi
• Urinary tract obstruction
• Acute prostatitis/abscess
• Renal insufficiency
• Instrumentation in patients with
bacteriuria
Genitourinary tract source
• Urethritis
• Cystitis
• Cervicitis
• Vaginitis
• Catheter-associated bacteriuria
Pelvic source
• PeritonitisAbscess
Upper respiratory tract source
• Pharyngitis, Sinusitis, Bronchitis, Otitis
media
Lower respiratory tract source
• Community-acquired pneumonia (with
asplenia)
• Empyema , Lung abscess
Lower respiratory tract source
Community-acquired pneumonia (in an
otherwise healthy host
Intravascular source
• Intravenous-line sepsis
• Infected prosthetic device
• Acute bacterial endocarditis
Skin/soft-tissue source
• Osteomyelitis
• Uncomplicated wound infections
Cardiovascular source
• Acute bacterial endocarditis
• Myocardial/perivalvular ring abscess
Cardiovascular source
• Subacute bacterial endocarditis
Central nervous system source
• Bacterial meningitis
Investigations and Treatment of Septicemia
• Very limited investigations can be done at the primary health care facilities (dispensary &
health center) therefore patients suspected of having septicemia should be referred to
hospitals.
Laboratory Studies
• Blood cultures
Blood cultures should be obtained in all patients upon admission to demonstrate the
organism responsible for the infection.
Negative blood culture results are also necessary to include pseudosepsis in the
differential diagnoses.
Complete blood count (CBC) count is usually not helpful because of the numerous
conditions that mimic sepsis (e.g. pseudosepsis) and that manifest as leukocytosis
Urine Gram stain, urinalysis, and urine culture if urosepsis is suspected.
Imaging Studies
• Chest Radiography
Is important to rule out pneumonia and diagnose other causes of pulmonary infiltrates.
• Ultra-sonography
Abdominal ultrasonography may be performed if biliary tract obstruction is suspected
based on the clinical presentation.
Sonograms in patients with cholecystitis may show a thickened gallbladder wall or
biliary calculi with dilatation of the common bile duct. Stones in the biliary tract are
visible in patients with cholangitis, but the common bile duct is dilated.
Abdominal ultrasonography is suboptimal for the detection of abscesses or perforated
hollow organs.
Treatment
• Few things can be done at the dispensary and health center to patients with septicemia.
Patients should be referred to the hospital immediately after resuscitation.
• At dispensary or health center, the following can be done before referral.
I/V fluids, I/V Antibiotics (broad-spectrum when available), Antipyretics and
monitoring of vital signs.
Manual provision of respiratory support (when in need)
Antimicrobial Therapy
• Appropriate antimicrobial therapy depends on an adequate coverage of the resident flora of
the organ system presumed to be the source of the septic process.
• Combination therapeutic agents include clindamycin or metronidazole plus levofloxacin,
or an aminoglycoside.
Complications
• Peritonitis may result in abscesses, which may subsequently need to be drained
• Inadequate correction of intra-abdominal perforation or drainage procedures may result in
a continuance or relapse of the patient's septic condition
• Cardiopulmonary complications-septic shock
• Renal complications-oliguria, azotaemia, proteinuria
• Coagulopathy
• Neurologic complications-polyneuropathy
Prognosis
• The prognosis in most patients is good, except in those with intra-abdominal or pelvic
abscesses due to organ perforation.
• The underlying physiologic condition of the host is the primary determinant of outcome.
• Early and appropriate empiric antimicrobial therapy and surgical intervention are critical         
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