WORLD SEPSIS DAY 13 SEPTEMBER ROLE OF DIAGNOSTIC MICROBIOLOGY

Dr.T.V.Rao MD
Sepsis continues to be a challenging task to the treating physicians with morbidity and higher mortality. Sepsis is defined as the presence (probable or documented) of infection together with systemic manifestations of infection. Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypo perfusion. Microbiology Departments have greater role to save several patients. We have poor infrastructure to serve ailing patients promptly, Many times patients are treated with empirical treatments till the events turn to the point of no return. Indias institutional and Subspecialty care has brought many matters to light and role of Microbiology in prompt recognition is well recognised. The prompt steps to early diagnosis include Screening for Sepsis and Performance Improvement 1. Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy. 2. Hospitalbased performance improvement efforts in severe sepsis

Diagnosis
1. Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial therapy To optimize identification of causative organisms, it is recommend obtaining at least two sets of blood cultures (both aerobic and anaerobic bottles) before antimicrobial therapy, with at least one drawn percutaneously and one drawn through each vascular access device, unless the device was recently (< 48 hours) inserted. These blood cultures can be drawn at the same time if they are obtained from different sites. Cultures of other sites (preferably quantitative where appropriate), such as urine, cerebrospinal fluid, wounds, respiratory secretions, or other body fluids that maybe the source of infection, should also be obtained before antimicrobial therapy if doing so does not cause significant delay in antibiotic administration Two or more blood cultures are recommended. In patients with indwelling catheters (for more than 48 hrs), at least one blood culture should be drawn through each lumen of each vascular access device (if feasible, especially for vascular devices with signs of inflammation, catheter dysfunction, or indicators of thrombus formation). Obtaining blood cultures peripherally and through a vascular access device is an important strategy. If the same organism is recovered from both cultures, the likelihood that the organism is causing the severe sepsis is enhanced 2. Use of the 1, 3 beta-D-glucan assay, mannan and anti-mannan antibody assays, if available and not to forget invasive candidiasis is in differential diagnosis of cause of infection. 3. Imaging studies performed promptly to confirm a potential source of infection Apart from identifying the source of infection it is the priority on Prevention Infection Prevention

1a.Selective oral decontamination and selective digestive decontamination should be introduced and investigated as a method to reduce the incidence of ventilator-associated pneumonia; this infection control measure can then be instituted in health care settings, all the health care workers are trained periodically on importance of basic care, and in regions where this methodology is found to be effective). 1b.Oral chlorhexidine gluconate be used as a form of oropharengeal decontamination to reduce the risk of ventilator-associated pneumonia in ICU patients with severe sepsis Diagnosis of systemic fungal infection (usually candidiasis) in the critically ill patient can be challenging, and rapid diagnostic methodologies, such as antigen and antibody detection assays, can be helpful in detecting candidiasis in the ICU patient. These suggested tests have shown positive results significantly earlier than standard culture methods, but false-positive reactions can occur with colonization alone and their diagnostic utility in managing fungal infection in the ICU needs additional study, needs clinical and diagnostic acumen, and coordination, jumping with conclusion with candidaemia and treating with toxic compounds adds to the problem.

Why we miss the Diagnosis of Sepsis

Sepsis is often diagnosed too late, because the clinical symptoms and laboratory signs that are currently used for the diagnosis of sepsis, like raised temperature, increased pulse or breathing rate, or white blood cell count are unspecific. In children, the signs and symptoms may be subtle and deterioration is rapid. Sepsis is under-recognized and poorly understood due to confusion about its definition among patients and healthcare providers, lack of documentation of sepsis as a cause of death on death certificates, inadequate diagnostic tools, and inconsistent application of standardized clinical guidelines to treat sepsis. Treating sepsis and associated morbidity and mortality can lead to conflict of interest and legal litigations. Rapid initiation of simple, timely interventions including antimicrobials, intravenous fluids and targeted treatment to restore the circulation can halve the risk of dying. Patients with suspected sepsis should be referred immediately to an appropriate facility. Early sepsis treatment is cost effective, reducing hospital and critical care bed days for patients; Patients with suspected sepsis should be referred immediately to an appropriate facility. Early sepsis treatment is cost effective, reducing hospital and critical care bed days for patients. Our Hospitals in Developing countries should initiate developing competent Microbiology Departments to reduce Morbidity and Mortality associated with Sepsis. It is aimed by 2020; all countries will have established learning needs for sepsis among health professionals and ensured the inclusion of training on sepsis as a medical emergency in all relevant undergraduate and postgraduate curricula. Recognition of sepsis by health professionals as a common complication of high-risk medical interventions will have significantly improved, thereby reducing the numbers of patients who become exposed to the risk. Recognition of sepsis by health professionals as a common complication of high-risk medical interventions will have significantly improved, thereby reducing the numbers of patients who become exposed to the risk of life. (Based on World Sepsis Day 2013 -The Global Sepsis Alliance (GSA) provides a look at sepsis facts and figures) Dr.T.V.Rao MD. Professor of Microbiology Freelance writer on Medicine and Microbiology. Email; doctortvrao@gmail.com