Sepsis Treatments and Medications

Sepsis is something most people only hear about in medical dramas. It’s rare for a healthy individual to become septic, but it still affects 1.7 million Americans a year and it can be fatal. 1 in 3 patients who dies in a hospital has sepsis, according to the Centers for Disease Control and Prevention. Older adults, pregnant women, children, people with underlying health conditions, and those with weakened immune systems are most vulnerable to sepsis if they contract even a minor infection. Here’s what you should know about the life-threatening condition and sepsis treatment options.

What is sepsis?

Sepsis is a rapidly progressing and life-threatening condition caused by the body’s overreaction to an infection. Normally, the body fights infection with an immune response directed at the infection site. Sepsis, however, is an immune reaction to an infection throughout the body. Called systemic inflammatory response syndrome (SIRS), sepsis puts into motion a cascade of effects that eventually results in organ dysfunction and death.

Also called septicemia, or sepsis syndrome, sepsis is commonly misunderstood as an infection, which it is not. Instead, sepsis is triggered by an infection. Bacterial, viral, or fungal infections can all provoke sepsis. Even the novel coronavirus that causes COVID-19 can cause sepsis. However, bacterial infections are the most common cause.

The immune system normally responds to an infection by producing inflammatory substances that kill the microorganism as well as surrounding tissues. The immune system dials up the immune system at the site of the infection and dials back the immune system in the rest of the body. It’s like the immune system presses the accelerator in one spot and slams on the brakes everywhere else.

Sometimes that balance falls out of whack and the immune system overreacts. Inflammatory substances circulate throughout the body, and the inner lining of the blood vessels produces substances that both damage blood vessels and cause them to grow wider. Fluid in the blood leaks out, and blood pressure goes down. The body compensates by speeding up the heart and breathing. This is the clinical definition of sepsis.

As more fluid leaks out of the bloodstream, blood pressure falls and tissues throughout the body stop receiving enough oxygen to carry on their functions. The condition is now a serious medical emergency called severe sepsis. Fluid continues to leak out of the blood vessels, blood clots begin to form in the bloodstream, lactic acid builds up, and blood cells become less flexible, further reducing oxygen flow to the body.

Septic shock occurs when blood pressure is too low to adequately fill the heart with blood, and tissues throughout the body are starved of oxygen. Vital organs begin to lose function and they eventually fail for lack of oxygen. Called multi-organ dysfunction syndrome (MODS), this is the final and often fatal stage in sepsis.

Worldwide, sepsis causes more deaths than any other cause. Globally, one in five deaths each year are due to sepsis. The majority are young children and 40% are young children under 5.

In the United States, however, infection prevention and widespread use of antibiotics make sepsis less of a threat than in other parts of the world. It is still a serious threat, however. The Centers for Disease Control and Prevention (CDC) estimate that 1.7 million people in the United States are struck with sepsis each year. A quarter-million of them die, representing about 10% of all registered deaths in the U.S.

Sepsis is so deadly because it can progress rapidly. Fortunately, sepsis can be medically managed, and people can recover. However, every minute counts, so it pays to know what it is and what to do when symptoms first appear.

How is sepsis diagnosed?

Sepsis is primarily diagnosed by physical symptoms, lab tests, and microbiology cultures.

Sepsis symptoms

Because sepsis can progress rapidly, it is important to know the initial symptoms and immediately seek medical attention. The symptoms of sepsis are:

• Fever or hypothermia

• Fast heartbeat

• Rapid breathing or hyperventilation

• Low blood pressure or hypotension is usually included in the symptoms of sepsis

The fourth criterion for a diagnosis of sepsis is an elevated white blood cell count, which can only be confirmed with a blood test. Any two of these four symptoms are sufficient for a sepsis diagnosis.

Risk factors

In taking a medical history, the healthcare provider will be particularly interested in risk factors that make sepsis potentially life-threatening, such as:

• Active cancer

• Diabetes

• Lung disease

• Congestive heart failure

• Liver disease

• Kidney problems

• A compromised immune system

The presence of any of these increased risks for severe sepsis will indicate the need for aggressive treatment from the outset.

Lab tests

Blood tests may confirm an infection and can show signs of organ failure. Blood cultures (and sometimes urine, joint fluid, or spinal fluid cultures) are used to identify the infecting organism.

Imaging

While imaging is not used to diagnose sepsis, it can help identify the site and extent of the infection. Chest X-rays, computerized tomography (CT scan), magnetic resonance imaging, or ultrasound are used to locate and define the infection.

Severe sepsis: hypotension

Severe sepsis is a life-threatening emergency. In addition to the symptoms of sepsis, its cardinal symptom is low blood pressure (hypotension). If at any time during an infection blood pressure falls, emergency medical treatment is usually required.

Other symptoms of severe sepsis may include altered mental state, disorientation, unconsciousness, blue skin, overly warm skin or cold skin, and either a decrease or increase in urine output.

Blood tests, cultures, and imaging will be used to diagnose and treat severe sepsis, but hospitalization is required. As a result, vital signs will be monitored continually, and blood tests will be performed regularly to monitor the progress of the condition.

Sepsis treatment options

Sepsis treatment follows a protocol based on the progress or severity of the condition. Survival depends on keeping blood pressure normal. Antibiotics are used from the beginning to manage the infection. Intravenous fluid replacement is used to replace lost blood volume. If blood pressure drops and cannot be improved with intravenous fluids, medications will be used to increase blood pressure.

Most people will initially be treated in an emergency room and then be hospitalized, most often in an intensive care unit (ICU). About one in seven people, however, will have a mild enough case of sepsis that they will be released from the emergency department for outpatient treatment.

Infection control

The first line of therapy against sepsis is to bring the infection under control with antibiotics. Patients are immediately given broad-spectrum antibiotics at the outset, but when the infecting organism is identified, an antimicrobial medication appropriate for that organism will be used. Surgery may be used to remove infected or dead tissue, such as an abscess.

Shock management

The goal of shock management is to prevent or reverse low blood pressure. Time is of the essence, so patients will be put on IV fluids to restore blood volume. If that does not work, medications that rapidly increase blood pressure will be administered. Most patients will be put on supplemental oxygen or mechanical ventilation to increase oxygen levels in the body.

When these measures fail, the patient may be put on medications that increase the force of the heart’s contractions or be given a packed red blood cell (pRBC) transfusion to increase blood flow if their blood count is low; this would not be done if they have a normal hemoglobin or blood count. In the most life-threatening cases, the patient may be put into an induced coma for several days using sedatives.

Sepsis medications

Sepsis medications focus on one of two goals: controlling the infection or restoring blood pressure. Any delay in treating the infection increases the chance of death, and controlling blood pressure is critical to survival.

Antibiotics

When all the signs point to sepsis, a physician will typically start the patient on a combination of broad-spectrum antibiotics that may include vancomycin, ceftriaxone, piperacillin-tazobactam, cefepime, tobramycin, imipenem-cilastatin, gentamicin, and others. Physicians will follow a protocol based on the location and source of the infection as well as the patient’s history with antibiotics. In addition, most hospitals currently employ an anti-microbial steward committee, which is usually headed by an infectious disease doctor. This is a group of healthcare providers tasked with ensuring the appropriate and judicious use of antibiotics in the hospital.

The goal of broad-spectrum antibiotic therapy is to kill as many types of bacteria as possible. Once the cultures have identified the microorganisms responsible for the infection, antibiotics that work the best against those organisms will be used. For out-patients with sepsis, oral antibiotics may sometimes be used, but hospitalized patients will be treated with intravenous antibiotics.

Other antimicrobial medications

For sepsis caused by viruses, an appropriate antiviral medication will be used. Some viruses, however, cannot be controlled by medications. Sepsis can also be caused by fungal infections, so amphotericin B or echinocandins such as Cancidas (caspofungin) or Mycamine (micafungin) will be used.

Vasopressors

Vasopressors are drugs that cause veins and arteries to contract and thus rapidly increase blood pressure. The first-line vasopressors for septic shock are the vasopressors epinephrine (adrenaline) and norepinephrine, but vasopressin is used if these drugs are not effective. To a lesser extent, these drugs also cause the heart to beat more forcefully, which also increases blood pressure and blood flow.

Corticosteroids

If vasopressors fail to increase blood pressure, corticosteroid injections can help the body compensate. Corticosteroids increase the kidney’s retention of sodium, which then increases the amount of water in the bloodstream, increasing both blood volume and pressure. However, corticosteroids should be used with caution in sepsis, as they have the potential to suppress the immune system and make the infection worse if not used in the right scenario.

Inotropes

When fluid replacement, vasopressors, and corticosteroid injections are unable to reverse shock, doctors will turn to inotropes or a red blood cell transfusion. Positive inotropes, dobutamine or milrinone, to increase the force of the heart’s contractions and increase the amount of blood pushed out with each heartbeat.

What is the best medication for sepsis?

Doctors prescribe medications for sepsis following well-known protocols based on the type of infection, lab results, and physical symptoms. There is, then, no “best” medication for sepsis, just the most appropriate set of medications for the medical situation.

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Best medications for sepsis