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Bacterial Sepsis Clinical Presentation

  • Author: Burke A Cunha, MD; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Mar 18, 2016
 

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.[11] 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.[16]

An acute surgical abdomen in a pregnant patient may be difficult to diagnose, but fortunately, most pregnant women are young, healthy, and physiologically strong.[17] 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.[17]

 
 
Contributor Information and Disclosures
Author

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of Ohio, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Department of Internal Medicine, Director of Infectious Disease Fellowship, Harper Hospital, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Thomas M Kerkering, MD Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine

Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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A right lower quadrant abdominal wall abscess and enteric fistula are observed and confirmed by the presence of enteral contrast in the abdominal wall.
Table 1. Clinical Conditions Associated With Sepsis
Associated With Sepsis (Fever ≥102°F) Not Associated With Sepsis (Fever ≤102°F)
GI tract source



Liver



Gallbladder



Colon



Abscess



Intestinal obstruction



Instrumentation



GI tract source



Esophagitis



Gastritis



Pancreatitis



Small bowel disorders



GI bleeding



GU tract source



Pyelonephritis



Intra- or perinephric abscess



Renal calculi



Urinary tract obstruction



Acute prostatitis/abscess



Renal insufficiency



Instrumentation in patients with bacteriuria



GU tract source



Urethritis



Cystitis



Cervicitis



Vaginitis



Catheter-associated bacteriuria (in otherwise healthy hosts without genitourinary tract disease)



Pelvic source



Peritonitis



Abscess



Upper respiratory tract source



Pharyngitis



Sinusitis



Bronchitis



Otitis



Lower respiratory tract source



Community-acquired pneumonia (with asplenia)



Empyema



Lung abscess



Lower respiratory tract source



Community-acquired pneumonia (in otherwise healthy host)



Intravascular source



IV line sepsis



Infected prosthetic device



Acute bacterial endocarditis



Skin/soft-tissue source



Osteomyelitis



Uncomplicated wound infections



Cardiovascular source



Acute bacterial endocarditis



Myocardial/perivalvular ring abscess



Cardiovascular source



Subacute bacterial endocarditis



  CNS source



Bacterial meningitis



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.[18]
Table 2. Noninfectious Conditions Mimicking Clinical and Hemodynamic Parameters of Sepsis
Clinical Presentations Mimicking Sepsis Hemodynamic Parameters Mimicking Sepsis
Hemorrhage Acute pancreatitis
Pulmonary embolism Anaphylaxis
Myocardial infarction Spinal cord injury
Pancreatitis Adrenal insufficiency
Diabetic (abdominal crisis) ketoacidosis  
Systemic lupus erythematosus flare with abdominal crisis  
Ventricular pseudoaneurysm  
Massive aspiration/atelectasis  
Systemic vasculitis  
Diuretic-induced hypovolemia  
Table 3. Characteristics of Pseudosepsis and Sepsis
Parameters Pseudosepsis Sepsis
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



Hemodynamic ⇓ PVR



⇑ CO



⇓ PVR



⇑ CO



Left ventricular dilatation



Laboratory ⇑ WBC count (with left shift)



Normal platelet count



⇑ FSP



⇑ Lactate



⇑ D-dimers



⇑ PT/PTT



⇓ Albumin



⇓ Fibrinogen



⇓ Globulins



⇑ WBC count (with left shift)



⇓ Platelets



⇑ FSP



⇑ Lactate



⇑ D-dimers



⇑ PT/PTT



⇓ Albumin



Clinical ≤102°F ±



Tachycardia ±



Respiratory alkalosis ±



Hypotension



≥102°F OR



Hypothermia ±



Mental status changes ±



Hypotension



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.
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