How to Predict the Risk of

Sepsis in Pneumonia
Dr. dr. Yani Jane Sugiri, Sp.P(K), FISR, FAPSR
Faculty of Medicine Brawijaya University – Dr. Saiful Anwar Hospital
Malang
 Introduction
• Sepsis is life threatening organ dysfunction caused by a dysregulated host
response to infection.1
• The most common site of infection is the lung (50%), followed by catheter-
associated bloodstream infection and urinary tract infection (20-25%), and
abdominal infection (15-20%).2
• Sepsis is the main complication of severe community acquired pneumonia
(CAP) observed in approximately one in three patients with severe CAP.3
• Early identification and appropriate management in the initial hours after
the development of sepsis improve outcomes.1
1. Surviving Sepsis Campaign. (2021). International Guidelines for Management of Sepsis and Septic Shock 2021
2. Rudd, K.E. et al. (2020). Global, regional, and national sepsis incidence and mortality.
3. Cilloniz et al. (2022). Host-targeted approaches to sepsis due to community-acquired pneumonia.
Introduction

• Sepsis : 1dari 10 penyebab kematian terbesar di dunia

• Salah satu penyebab terbanyak sepsis : pneumonia
• Di Indonesia prevalensi pneumonia tahun 2013 4,5%, termasuk 10
besar penyakit penyebab rawat inap .

• Gold standar diagnosis sepsis: kultur darah

• Gejala sepsis beragam, skrining dapat menggunakan skor SOFA,

qSOFA, biasanya pasien datang kondisi berat dan diperlukan
parameter biokimia/ biomarker yang spesifik dan sensitif

Kepatuhan dalam tatalaksana resusitasi dan sepsis bundles dan dapat

menurunkan mortalitas pasien sepsis

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 Epidemiology
• Sepsis affects 1.7 million adults in the USA annually, with nearly
270,000 deaths.4
• A global study reported a decrease of 18.8% in sepsis incidence
worldwide from 60 million cases in 1990 to 49 million cases in 2017.4
• Common pathogens : gram negatives 67% (Klebsiella spp, E. Coli,
Pseudomonas aeruginosa, Enterobacteriacea) ; gram positives 37% ;
fungsi 16%.4

4. Niederman et al. (2021). Initial antimicrobial management of sepsis.

Epidemiology
Mortality by cause, world, 2019 Penyebab Kematian Karena Infeksi pada Anak Usia di Bawah 5 Tahun

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 Risk Factor of Pneumonia
• Incidence hospitalization of CAP in adult ≥ 65 yo 🡪 2000/100.000 in
Age US

• Chronic lung disease(COPD, Bronchiectasis, Asthma), Chronic heart

Comorbid
disease, CVA, DM, Malnutrition, Immunocompromised condition

Respiratory Tract • Primary Viral Pneumonia, Predisposition of Secondary Bacterial

Infection Pneumonia
• Change in Conciosness (CVA, Convulsion Anesthesia, Drug/Alcohol
Functional Disorder
User), Disfagia (Dismotility)

Smoking • Exposure to environment

5. Konsensus PDPI, CAP. 2022

Diagnosis of Community Acquired Pneumonia (CAP)

Chest radiography or other chest imaging demonstrating an infiltrate

or air-bronchogram confirms the diagnosis, plus acute onset of:
• Cough (productive or nonproductive)
• Changes in sputumcharacteristics, usually purulent
• Axilla temperature >38oC or history of fever
• Chest pain with inspiration and coughing
• Dyspnea
• Signs of consolidation, bronchial breath sound and rales
• Leucocyte ≥10.000 cells/mm3 or <4.500 cells/mm3 with
neutrophilia segment/immature
5. Konsensus PDPI, CAP. 2022
2 Major Principles Diagnosis of CAP6

1 Define if
2 Presence of
severe or non risk factors for
severe MRSA or PSA

6. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

 American Thoracic Society Criteria for Defining Severe CAP6

Minor Criteria
• Respiratory rate breaths per minute
• PaO2/FiO2 ratio 250
• Multilobar infiltrates
• Validated definition includes :
Confusion/disorientation
• Uremia (BUN 20 mg/dL) Either 1 major criteria OR 3 more minor criteria
• Leukopenia (<4,000 cells/mm3)
• Thrombocytopenia (<100,000 cells/mm3)
• Hypothermia (core temperature <36◦C)
• Hypotension requiring aggressive fluid resucitation

Major Criteria
• Septic shock with need for vasopressors
• Respiratory failure requiring mechanical ventilation

6. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

 Risk Factors for MRSA7
Methicillin-Resistant Staphylococcus aureus
• Previous infection/colonization by MRSA in the last 12 months
• Hemodialysis or peritoneal dialysis
• Presence of central venous catheters or intravascular devices
• Administration of multiple antibiotics in the last 30 days (in particular with cephalosporins or
fluoroquinolones)
• Immunodepression
• Immunosuppressor treatments
• Rheumatoid arthritis
• Drug addiction
• Patients coming from long-term care facilities or who have undergone hospital stay in the last 12
months
• Close contact with patients colonized by MRSA

7. J. Clin. Med. 2023, 12, 3188. https://doi.org/10.3390/jcm12093188

 Risk Factors for PSA7
Pseudomonas aeruginosa
• Previous infection/colonization with P. aeruginosa in the last 12 months
• Administration of multiple antibiotics in the last 30 days (particularly with cephalosporins or
fluoroquinolones)
• Pulmonary anatomic abnormalities with recurrent infections (e.g., bronchiectasis)
• Elderly patients (>80 years)
• Scarce glycemic control in diabetic subjects
• Presence of permanent urinary catheter
• Prolonged steroid use (>6 weeks)
• Neutropenic fever
• Cystic fibrosis

7. J. Clin. Med. 2023, 12, 3188. https://doi.org/10.3390/jcm12093188

 CURB-65 Score5

5. Konsensus PDPI, CAP. 2022

PORT (Pneumonia Patient Outcome Research Team)
PSI (Pneumonia Severity Index)5

5. Konsensus PDPI, CAP. 2022

• A higher percentage of patients in the sepsis group was classified as PSI risk classes IV–V, and
more experienced a higher rate of severe CAP compared with the no sepsis group.
• 71% very old patients (≥ 80 years) hospitalized with CAP presented with sepsis and 7% presented
with septic shock.
• Male sex, chronic renal disease, and diabetes mellitus were independent risk factors for
presenting with sepsis, where as antibiotic therapy in the week prior was a protective factor.
• Greek study described comorbidities that contribute to the development of sepsis in patients
with CAP, namely diabetes mellitus, chronic heart failure, coronary heart disease, and dementia.

J. Clin. Med. 2019. Risk and Prognostic Factors in Very Old Patients with Sepsis Secondary to Community-Acquired Pneumonia
Sepsis is life-threatening
organ dysfunction caused
by a dysregulated host
response to infection

Septic Shock: Subset of

sepsis with circulatory and
cellular/metabolic
dysfunction associated
with higher risk of mortality

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16
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 • qSOFA ditetapkan oleh The Third International Consensus Definitions for Sepsis and Septic Shock pada tahun 2016
untuk menyederhanakan versi SOFA tanpa pemeriksaan laboratorium.
• qSOFA dapat diasses pada saat pertama pasien datang di RS (Spanuth et al.,2017).

Quick SOFA criteria (qSOFA)

• Respiratory rate ≥22/min
• Altered mentation
• Systolic blood pressure ≤100 mm Hg
• Non-ICU patients with qSOFA = 2-3 are at increased risk of death or prolonged ICU stay (> 3 days) (Singer et al., JAMA.,
2016)

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 Limitations of SOFA + qSOFA
•SOFA and qSOFA scores were designed as research tools at a population level to predict which patients with
sepsis were likely to die...they do not define sepsis
•Clinical deterioration in patients with a positive qSOFA score may be due to causes other than sepsis
•New organ dysfunction should prompt you to consider occult infection
•*** The addition of serum lactate to qSOFA did not significantly change the ability of qSOFA to predict mortality.

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Severity of
Sepsis8

8. Carnieror et al. (2017). Dear Sepsis-3, we are sorry to say that we don’t like you
Sepsis-3:
Sepsis and
Septic Shock

4. Carnieror et al. (2017). Dear Sepsis-3, we are sorry to say that we don’t like you
Sepsis Diagnosis According to The Latest
Guidelines

We recommend against using qSOFA compared with

SIRS, NEWS, or MEWS as a single screening tool for
sepsis or septic shock.1

Quality of evidence : Moderate

1. Surviving Sepsis Campaign. (2021). International Guidelines for Management of Sepsis and Septic Shock 2021
 SSC 2021 : Activate within One Hour of
Presentation
• Blood cultures
Drawn before antibiotic and within 1 hour after TOP (time
of presentation).
• IV Broad Spectrum Antibiotic
Start within 1 hour after TOP unless given within past 24
hours.
• Lactate
Drawn within 1 hour after TOP.
• IV fluid bolus (0.9% NS or LR)
Min 30 mL/kg only if Septic Shock present.
Start within 1 hour after TOP and complete within 3 hours.

1. Surviving Sepsis Campaign. (2021). International Guidelines for Management of Sepsis and Septic Shock 2021
 Initial Resuscitation in Septic Shock
Fluid
• Balanced solution may be better than saline
• Albumin 4-5 % may still be considered in certain cases

Vasopressor
• Norepinephrine is still recommended as first-line vasopressor therapy
• Some recommend using vasopressors early, along with fluid resuscitation
• The use of dopamine is not recommended as a vasopressor of choice because it can induce unfavorable
tachycardia, however, it may still be considered if there is evidence of bradycardia orrelative bradycardia.

1. Surviving Sepsis Campaign. (2021). International Guidelines for Management of Sepsis and Septic Shock 2021
 Antibiotic Timing

• For adults with possible septic shock or a high like

lihood for sepsis, we recommend administering
antimicrobials immediately, ideally within one hour
of recognition.
• For adults with suspected sepsis or septic shock, we
suggest against using procalcitonin plus clinical
evaluation to decide when to start antimicrobials,
as compared to clinical evaluation alone.

1. Surviving Sepsis Campaign. (2021). International Guidelines for Management of Sepsis and Septic Shock 2021
 Antibiotics
Standart β laktam (sefotaksim, seftriakson atau ampisilin sulbaktam) AND Macrolide (azithromycin;
clarithromycin)
Regimen OR FQ (levofloxacin; moxifloxacin) AND β lactam

PSA Antipneumokokal, antipseudomonas β laktam (piperasilin-tazobactam, cefepime,

ceftazidime, imipenem, meropenem atau aztreonam) AND Levofloxacin 750 mg
Coverage OR β laktam as above AND aminoglikosida AND azitromisin
OR β laktam as above AND aminoglikosida AND antipneumokakal florokuinolon (penicillin
allergy, β laktam change aztreonam)

MRSA AND vankomisin OR linezolid

Coverage
1. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019
 Corticosteroids
• In patients with septic shock and requiring vasopressor therapy, IV
corticosteroids are recommended.
• Choice of corticosteroids:
IV hydrocortisone at a dose of 200 mg/day given intravenously 50 mg
every 6 hours or as a continuous infusion).
• It is recommended to initiate corticosteroid therapy when the dose of
norepinephrine or epinephrine reaches 0.25 mcg/kg/minute at least 4
hours after initiation.

1. Surviving Sepsis Campaign. (2021). International Guidelines for Management of Sepsis and Septic Shock 2021
• The qSOFA and the CRB scores proved more clinically useful than the SIRS as tools for prompt
management of patients with CAP in Emergency Department.
• Severe CAP and a high inflammatory response (CRP >150 mg/L) that the use of
methylprednisolone (0.5 mg/kg twice a day for five days) was related to a lower rate of
treatment failure (13% vs. 31%, including radiographic progression, late mechanical
ventilation, and septic shock).

Cilloniz et al. 2022. Host-targeted approaches to sepsis due to community-acquired pneumonia.

 Case Discussion
Mr. S / 80 years old
Day-1

Subjective Objective Laboratory CXR

Gradual decrease of
consciousness (+) GCS 345
BP 70/52 mmHg Leukocytes 21,840
Shortness of breath (+) Neutrofile 93
HR 134 x/m
Fever (+) RR 32 x/m OT/PT 507/128
T 38,5 Ur/Cr 63,1/1,09
Productive cough with
greenish sputum (+) Spo2 85% on RA eGFR 80,698
Pulmo CRP 23,9
History of smoking + Procal 78,5
Rh +++/+++ Wh --+/-++ BGA
7,29/73,7/90,9/36,1/9,3
/97
Lactat Acid 2,1
 Case Discussion
Mr. S / 80 years old Day-1

Assesment Therapy

Severe CAP, CURB-

65 (score 4), PSI O2 HFNC FiO2 60% Flow 45 lpm
Loading NS 1000cc 🡪 Maintenance NS 0,9% 1500
110 RC IV cc/24hours
Drip NE start 0,05-0,2 mcg/kgBB/minute
IV Levofloxacin 1x750 mg
IV Ceftriaxone 2x1 gram
IV Metilprednisolon 2x62,5 mg
Septic Shock PNGT NAC 3x400 mg
PNGT Curcuma 3x1 tab
(SOFA score 🡪 6) Nebul Ipratropium Bromide + Salbutamol 3x1 respul
Nebul Budesonide 2x2 respul
 Case Discussion
Mr. S / 46 years old Day-7
Sputum DST TCM CXR

Achromobacter MTB not

xylosoxidans XDR detected

Sensitif :
Meropenem
 Conclusion
• Sepsis is a life threatening organ dysfunction caused by dysregulated
host response to infection
• Predictions for sepsis in pneumonia can be seen from risk factors such as
old age and comorbid diseases.
• Curb-65 and PSI are only used for pneumonia mortality but not for
predicting sepsis, however, it was found that PSI IV - V scores were more
likely to cause sepsis.
• The updated sepsis guideline provides strong recommendations for
numerous elements of standardized care, including antimicrobial
therapy, initial fluid volume, blood pressure goals, and vasopressor
choice.
TERIMA KASIH

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