Bacterial Sepsis Clinical Presentation

Updated: Feb 05, 2019
  • Author: Amber Mahmood Bokhari, MBBS; Chief Editor: Michael Stuart Bronze, MD  more...
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Presentation

History and Physical Examination

Nonspecific signs and symptoms

The history and physical examination findings are nonspecific but may suggest the likely source of the septic process and thereby help determine the appropriate antimicrobial therapy and other interventions. General signs and symptoms of sepsis may include the following:

  • Fever, with or without shaking chills (temperature >38.3ºC or < 36ºC)
  • Impaired mental status (in the setting of fever or hypoperfusion)
  • Increased breathing rate (>20 breaths/min) resulting in respiratory alkalosis
  • Warm or cold skin, depending on the adequacy of organ perfusion and dilation of the superficial skin vessels
  • Hypotension requiring pressor agents to maintain systolic blood pressure above 65 mm Hg

Systemic signs and symptoms

The clinical features depicted below may provide important diagnostic clues.

Respiratory infection

Cough, chest pain, and dyspnea may suggest pneumonia or empyema but may also be observed in patients with pulmonary embolism or pleural effusion.

Gastrointestinal  (GI) or  genitourinary  (GU) infection

The patient may have a history of antecedent conditions predisposing to perforation or abscess. 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 or generalized peritonitis, whereas right upper abdominal quadrant (RUQ) tenderness may suggest a biliary tract etiology (eg, cholecystitis, cholangitis), and tenderness in the right lower abdominal quadrant (RLQ) suggests appendicitis or Crohn disease. Discrete tenderness over the left lower abdominal quadrant suggests 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 prostatitis.
  • A urinary tract source is suggested by an antecedent history of pyelonephritis, stone disease, congenital abnormal collecting system, prostatic hypertrophy, or previous operations or procedures involving the prostate or kidneys. [32, 33] Costovertebral angle tenderness with a fever suggests acute pyelonephritis. Subacute or chronic pyelonephritis may manifest as only mild tenderness.

Intravenous  line infection

Evidence of infection at a central IV line site suggests the probable etiology. [34] However, it is important to note that many patients with central IV line infections do not have superficial evidence of infection at the insertion site. Always suspect IV line infections, especially when other sources of sepsis are eliminated. [35, 36] Central IV lines are the lines most commonly associated with bacteremia or sepsis.

Peripheral venous lines and arterial lines are rarely associated with bacteremia. Thrombophlebitis may be noted at the peripheral IV line site.

Surgical wound infection

Pain, purulent exudate, or crepitus in a surgical wound may suggest wound infection, cellulitis, or abscess.

Signs of end-organ hypoperfusion

These signs include the following:

  • Warm, flushed skin may be present in the early phases of sepsis. The skin may become cool and clammy with progression to shock due to redirection of blood flow to core organs. Decreased capillary refill, purpura cyanosis, or mottling may be seen.
  • Altered mental status, obtundation, restlessness
  • Oliguria or anuria due to hypoperfusion
  • Ileus or absent bowel sounds

Special considerations

Elderly patients may present with peritonitis and may not experience rebound tenderness of the abdomen. [37]

Elderly individuals, persons with diabetes, and patients on beta-blockers may not exhibit an appropriate tachycardia as blood pressure falls.

Younger patients develop a severe and prolonged tachycardia without hypotension until acute decompensation occurs.

Patients with chronic hypertension may develop critical hypoperfusion at a blood pressure that is higher than in healthy patients (ie, relative hypotension).

An acute surgical abdomen in a pregnant patient may be difficult to diagnose. [38] The most common cause of sepsis in pregnancy is urosepsis. [38]