Pak J Med Res Original Article

Vol. 54, No. 2, 2015

Clinical Profile and Disease Outcome of Septic Patients at

Public Sector Hospital
Naheed Hashmat1, Iffat Shabbir2, Tayyaba Rahat3, Farooq Ijaz4, Saadia Majeed5
Department of Medicine1,4,5, PMRC Research Centre2,3, Fatima Jinnah Medical College, Sir Ganga Ram Hospital,
Lahore
Received: 14 June 2014, Accepted: 21 January 2015, Published: 26 June 2015

Abstract
Objective: To correlate the clinical profile with disease outcome of patients suffering from septicemia.
Study type, settings and duration: This descriptive study was conducted from January to April 2014 at the medical unit of Sir
Ganga Ram Hospital Lahore.
Patients and Methods: A total of 50 Adults admitted to medical unit of Sir Ganga Ram Hospital Lahore, with signs and
symptoms suggestive of systemic inflammatory response secondary to infection were selected and categorized according to
criteria by the American College of Chest Physicians (ACCP) and Society of Critical Care Medicine (SCCM). Demographic
data. Clinical profile eg and biochemical investigation including liver and renal function tests, coagulation profile, serum
electrolytes and serum lactate levels were recorded on a predesigned questionnaire. Data analysis was done by using SPSS-20.
Results: A total 50 patients were admitted with septicemia. They were distributed as per ACCP criteria into three classes i.e.
sepsis 25 (50%), severe sepsis 16 (32%), and septic shock 09 (18%). The most common causes of sepsis were urinary tract
infection (46%); followed by pneumonia (32%); gastroenteritis (16%) and others (06%). E.coli was the predominant organism
isolated in 44.5% urine samples. Comorbids included, 22% diabetics, 16% chronic kidney disease, 14% hypertensive, 10%
chronic liver disease, 10% pulmonary tuberculosis and 4% cases chronic obstructive airway diseases. Out of 50 patients, 35
(70%) recovered and 15 (30%) expired. Disease severity was directly related to the mortality and 78% cases having septic shock
expired as compared to 31% with severe shock. Comorbids, blood CP and serum lactate level did not show any significant
association between disease severity and its outcome.
Conclusion: Disease severity was directly related to disease outcome. No association found between serum lactate, disease
severity and its outcome.
Policy Message: Standardized management protocol adapted from the current guidelines particularly low-cost interventions
targeted at early sepsis needs to be developed and implemented.
Key words: Sepsis, severe sepsis, septic shock, post infection sepsis, serum lactate.

Pakistan Journal of Medical Research, 2015 (April - June) 44

 Naheed Hashmat, Iffat Shabbir, Tayyaba Rahat, Farooq Ijaz, Saadia Majeed
Introduction
epsis is a syndrome of bacterial infection
S manifesting as a systemic inflammatory response
which may eventually lead to organ injury1. Sepsis and
septic shock remain a major cause of morbidity and
mortality in developed and developing countries2-4, The
mortality rate from severe sepsis in the developed
countries has been estimated as being between 28 and
50% 5.
In the UK alone it claims between 36,000 to
64,000 lives per year 1 and in United States the rate of
sepsis-associated mortality was reported to be 50.37
deaths per 100,000, from the years 1999-2005 6. In
Germany sepsis is responsible for 60,000 lost lives every
year and is the third most common cause of death 4. It has
been documented that sepsis is responsible for 60-80%
deaths in developing countries including Pakistan7. Poor
hygiene, low standards of living, malnutrition, lack of
adequate health care facilities and resources are
contributory to the disproportionately high mortality 8.
Population and the extremes of age’s, infants
and children and the elderly are the most vulnerable and
so are people with chronic illness like diabetes mellitus,
kidney and liver disease9. The number of cases has been
on the rise due to aging population, increasing lifespan of
people with chronic illnesses and spread of antibiotic
resistant organisms9,10
The current diagnosis of sepsis and septic shock is based
on the criteria set out by the American College of Chest
Physicians / Society of Critical Care Medicine
(ACCP/SCCM) conference of 1992 11. The use of these
criteria is helpful in diagnosing patients with sepsis,
severe sepsis and septic shock. This study is designed to
look at the clinical profile and disease outcome of
patients presenting with sepsis to a medical ward at a
tertiary care hospital.
Patients and Methods
The study was approved by the Institutional
Ethical Review Board (IERB) of Fatima Jinnah Medical
College, Lahore. The study was conducted in the
nephrology section of medical unit of a tertiary care
hospital from January to April 2014. All patients
admitted with signs and symptoms suggestive of systemic
inflammatory response secondary to infection were
included in the study. According to criteria by the
Corresponding Author:
Iffat Shabbir
PMRC Research Centre
Fatima Jinnah Medical College, Lahore .
Email: shabbiriffat@yahoo.com
45
American College of Chest Physicians (ACCP) and
Society of Critical Care Medicine (SCCM), all patients
were categorized into three groups i.e. sepsis, severe
sepsis and septic shock10. Demographic profile, co-
morbid conditions, presenting signs and symptoms,
detailed physical examination data was recorded on a
predesigned questionnaire.
Biochemical investigation including liver and
renal function tests, coagulation profile, serum
electrolytes and serum lactate levels were done. Other
investigations included chest X-ray, abdominal
ultrasound and ECG. Culture & sensitivity test of
different specimens was carried as per requirement.
Data analysis was done by using SPSS-20.
Categorical variables were described as frequency
percentage. Numerical variables were presented as mean
± SD. Chi square was used to find the association
between disease severity, its outcome and serum lactate.
p-value ≤0.05 was considered as significant.
Results
A total of 61 patients admitted with signs and
symptoms suggestive of systemic inflammatory response
secondary to infection, among them 50 fulfilled the
inclusion criteria and were analyzed. The mean age of
patients was 5021 years; and male to female ratio was
1:1.5. As per the ACCP criteria, 25 (50%) patients had
sepsis, 16 (32%) severe sepsis; and 9 (18%) septic shock.
The most common cause of sepsis seen was Urinary
Tract Infections (46%); followed by Pneumonia (32%);
Gastroenteritis (16%) and others (06%).
Out of 50 enrolled cases, 43 specimens of 22
(44%) patients were tested for culture and sensitivity. All
blood specimens tested for bacterial culture yielded no
growth. Eight urine specimens (44.5%) yielded bacterial
growth of E.coli. Only one HVS specimen was subjected
to culture that yielded bacterial growth of Staph aureus.
Almost 22% patients were diabetic, 16% had
chronic kidney disease, 14% were hypertensive, 10% had
chronic liver disease, 10% pulmonary tuberculosis and
4% cases had chronic obstructive airway diseases.
Table-1 shows the mortality data. Out of 50
cases, 35 (70%) survived and 15 (30%) expired. Disease
severity was directly related to mortality as 78% cases
having septic shock syndrome expired against 31% with
severe sepsis and 12% with sepsis alone.
Serum lactate values were also seen and
compared with the severity of disease. The lactate values
were elevated above normal in 25 cases (50%). Mean
lactate level of (2.23±1.87 mmol/L) septic shock patients
was greater than of sepsis patients (2.09±1.61 mmol/L).
Pakistan Journal of Medical Research, 2015 (April - June)
 Clinical Profile and Disease Outcome of Septic Patients at Public Sector Hospital

ACCP/SCCM consensus conference criteria for the systemic inflammatory response syndrome, sepsis, severe sepsis and
septic shock

The systematic inflammatory response is manifested with two or more of the following criteria:
➢ Fever (body temperature >38° C )or hypothermia (body temperature <36° C)
Systemic Inflammatory Response ➢ Tachycardia (heart rate >90 beat/min)
Syndrome (SIRS) ➢ Tachypnea (>20 breaths/min) or PaCo2 <4.3 kPa
➢ Leukocytosis or leucopenia (white blood cell count >12,000 or <4,000/mm3) or >10%
immature forms
Presence of SIRS in response to infection. SIRS in manifested by two or more of the criteria
Sepsis mentioned above
➢ Sepsis associated with organ dysfunction, hypo perfusion or hypotension
Severe sepsis ➢ Organ dysfunction and hypo perfusion abnormalities may include, but are not limited to
lactic acidosis oliguria, or an alteration in mental status.
➢ Sepsis with hypotension despite adequate fluid resuscitation, along with the presence of
perfusion abnormalities
Septic Shock ➢ Hypotension is defined as a systolic blood pressure <90 mm Hg or a decrease of systolic
blood pressure by 40 mmHg or more from the baseline

Table 1: Disease Outcome as per sepsis classification and

serum lactate levels. Discussion
Serum
Patients Patients Mean In this study, septicemia was mostly related to
Sepsis Lactate
Recovered Expired Serum urinary tract infection and E.coli was the causative
Classification >4.0
(n=35) (n=15) Lactate
mmol pathogen. Mortality was mostly related to the severity of
Sepsis(n=25)
22 3 3
2.09±1.61 infection i.e. it was maximum in septic shock syndrome
(88.0%) (12.0%) (12.0%) followed by severe septicemia. Old aged patients
Severe 11 5 1
Sepsis(n=16) (68.8%) (31.2%) (6.2%)
2.00±1.46 succumbed more to disease as compared to younger ones.
Septic 2 7 1 Mean age of admitted patients was 5021 years and
2.23±1.87
Shock(n=9) (22.2%) (77.8%) (11.1%) majority of the patients (40%) age ranged between 40-60
years. In our study, 22% patients had diabetes, 16% had
It was also seen that lactate levels >4.0 mmol/L, a marker chronic kidney disease, 14% had hypertension, 10%
of severe disease was seen in 10% of the cases. Of them chronic liver disease, 10% pulmonary tuberculosis and
(40%) expired. However, no significant association was 4% chronic obstructive airway diseases. Silva et al 12
found between serum lactate, disease severity and its reported a similar frequency of 21.7% of diabetes but
outcome. their chronic kidney disease was 50% less than ours
The comparison of biochemical tests between (7.5%). Sreedharan et al 13 reported twice high diabetes
patients who recovered and those who could not recover (45%) and 34.2% hypertension in their study as
is shown in Table-2. Patients having older age and signs compared to ours. No association of co-morbid
of septic shock like low systolic and diastolic blood conditions was seen with mortality in our study and same
pressure, high pulse and respiratory rate expired. findings were the given in other studies 14,15. In our study,
the most common cause of sepsis was the urinary tract
Table 2: Clinical profile of recovered and expired septic infection (46%) followed by pneumonia 32% and the
patients. gastrointestinal tract 16%. Similar findings were reported
by other worker16 while, another study reported
Recovered Expired pneumonia to be the most common cause followed by
Parameters
(N=35) (N=15) urosepsis17.
Age 44.49±20.14 62.53±18.33 In the present study, blood and urine specimens
Systolic Blood Pressure 120.86±28.74 108.00±31.21
of 22 (44%) patients were tested for culture and
Diastolic Blood Pressure 78.29±15.19 64.67±24.46
Pulse Rate 91.74±17.45 110.07±19.33 sensitivity. All blood specimens were negative on the
Respiratory Rate 19.08±3.49 24.50±5.53 culture while 08 urine specimens (44.5%) yielded growth
Hemoglobin 10.14±2.30 10.70±2.77 of E.coli. A study concluded elsewhere that causative
WBCs Count 14.65±7.31 16.03±8.28 pathogen could not be identified in approximately one
Platelets Count 257.13±160.6 212.00±82.60
Blood Urea Nitrogen 76.13±69.39 63.50±52.70 third of their sepsis patients18. Conventional laboratory
Serum Creatinine 3.56±4.63 2.47±2.07 data which includes a white cell count, platelet count,
Total Bilirubin 1.88±3.30 2.32±2.73 serum bilirubin and lactate levels are easy to measure but

Pakistan Journal of Medical Research, 2015 (April - June) 46

 Naheed Hashmat, Iffat Shabbir, Tayyaba Rahat, Farooq Ijaz, Saadia Majeed
are also nonspecific19. Similar are the findings was also
found of the present study.
Elevated serum lactate as a manifestation of
organ dysfunction is used as a marker of severe disease 20-
22
but in the present study only 05 (10%) patients had
serum lactate levels >4.0 mmol/L.
Almost 30% patients expired. The death mostly
occurred in patients having septic shock and same has
been reported previously5.
The limitations of this study were that the
sample size was small, and since it was conducted in
nephrology section attached with medical unit, while
might explain the higher percentage of cases of urosepsis.
The study highlights the importance of early recognition
and treatment of patients with sepsis. The World Sepsis
Declaration has set a target to reduce the incidence of
sepsis by 2020 by 20%, by providing clean water,
vaccination, good nutrition and education of public
regarding the practice of hand washing and maintaining
good hygiene22. Future developments will focus on sepsis
biomarkers and microarray technique to rapidly screen
for pathogens and the development of novel therapeutic
agents targeting immuno-modulation.
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