Bacterial Sepsis Clinical Presentation
- Author: Burke A Cunha, MD; Chief Editor: Michael Stuart Bronze, MD more...
History and Physical Examination
The patient’s history is essential in determining the likely source of the septic process. This, in turn, determines the appropriate antimicrobial therapy (see Treatment). In addition, the physical examination may be helpful in suggesting a potential source for sepsis.
Patients with nonspecific symptoms are usually acutely ill with fever, with or without shaking chills. Mental status may be impaired in the setting of fever or hypoperfusion. Patients with bacteremia from any source often display an increased breathing rate resulting in respiratory alkalosis. The skin of patients with sepsis may be warm or cold, depending on the adequacy of organ and skin perfusion.
Intravenous line infections
An infected central intravenous (IV) line site immediately suggests the probable etiology. However, it is important to note that only 50% of patients with central IV line infections have evidence of infection at the insertion site.
Suspect IV line infections when other sources of sepsis are eliminated and the IV line has been in place for a prolonged period, usually longer than 1 week.[12, 13] Central IV lines are the lines most commonly associated with bacteremia or sepsis. Peripheral venous lines and arterial lines are rarely associated with bacteremia.
Gastrointestinal and genitourinary infections
As noted, in many cases, the history is critical for diagnosis. Abdominal findings on physical examination may be absent or unimpressive.
Patients with an intra-abdominal or pelvic source of infection usually have a history of antecedent conditions that predispose to perforation or abscess (eg, chronic or retrocecal subacute appendicitis, diverticulitis, Crohn disease, previous abdominal surgery, or cholecystitis).
Diffuse abdominal pain may suggest pancreatitis (not sepsis) or generalized peritonitis, whereas right upper abdominal quadrant (RUQ) tenderness may suggest a gallbladder etiology (eg, cholecystitis, cholangitis), and tenderness in the right lower abdominal quadrant (RLQ) in a young adult suggests appendicitis or Crohn disease. Discrete tenderness over the left lower abdominal quadrant is suggestive of diverticulitis, particularly in elderly patients.
A rectal examination may reveal exquisite tenderness caused by a prostatic abscess or, more commonly, an enlarged noninflamed prostate suggestive of benign prostatic hyperplasia (BPH).
A urinary tract source is suggested by an antecedent history of pyelonephritis, stone disease, congenital abnormal collecting system, prostate enlargement, or previous operations or procedures involving the prostate or kidneys.[14, 15] Costovertebral angle tenderness with a temperature of 102°F suggests acute pyelonephritis. Subacute or chronic pyelonephritis may manifest as only mild tenderness.
Elderly or pregnant patients
Elderly patients may present with peritonitis and may not experience rebound tenderness of the abdomen.
An acute surgical abdomen in a pregnant patient may be difficult to diagnose, but fortunately, most pregnant women are young, healthy, and physiologically strong. The most common cause of sepsis in pregnancy is urosepsis due to an obstructed urinary tract, which may be caused by the hormonal effects of pregnancy on the ureters (hydroureters) and the mechanical obstructing effect of the uterus impinging on the ureters.
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|Associated With Sepsis (Fever ≥102°F)||Not Associated With Sepsis (Fever ≤102°F)|
|GI tract source
|GI tract source
Small bowel disorders
|GU tract source
Intra- or perinephric abscess
Urinary tract obstruction
Instrumentation in patients with bacteriuria
|GU tract source
Catheter-associated bacteriuria (in otherwise healthy hosts without genitourinary tract disease)
|Upper respiratory tract source
|Lower respiratory tract source
Community-acquired pneumonia (with asplenia)
|Lower respiratory tract source
Community-acquired pneumonia (in otherwise healthy host)
IV line sepsis
Infected prosthetic device
Acute bacterial endocarditis
Uncomplicated wound infections
Acute bacterial endocarditis
Myocardial/perivalvular ring abscess
Subacute bacterial endocarditis
|CNS = central nervous system; GI = gastrointestinal; GU = genitourinary; IV = intravenous.|
|Adapted from: Cunha BA, Shea KW. Fever in the intensive care unit. Infect Dis Clin North Am. Mar 1996;10(1):185-209.|
|Clinical Presentations Mimicking Sepsis||Hemodynamic Parameters Mimicking Sepsis|
|Myocardial infarction||Spinal cord injury|
|Diabetic (abdominal crisis) ketoacidosis|
|Systemic lupus erythematosus flare with abdominal crisis|
|Microbiologic||No definite source PLUS ≥1 abnormalities
Negative blood cultures excluding contaminants
|Proper identification/process/source PLUS ≥1 microbiologic abnormalities
Positive buffy coat smear result OR 2/3 or 3/3 positive blood cultures
Left ventricular dilatation
|Laboratory||⇑ WBC count (with left shift)
Normal platelet count
|⇑ WBC count (with left shift)
Respiratory alkalosis ±
Mental status changes ±
|CO = cardiac output; FSP = fibrin split products; GI = gastrointestinal; GU = genitourinary; PT/PTT = prothrombin time/partial thromboplastin time; PVR = peripheral vascular resistance; WBC = white blood cell.|