Sepsis Diagnosis and Management

Definition and Criteria

Sepsis requires documented or suspected infection PLUS evidence of organ dysfunction (SOFA score ≥2 points), as defined by the Society of Critical Care Medicine 1, 2
The American College of Critical Care Medicine recommends evaluating a patient's presentation against these criteria, including infection and organ dysfunction 1, 2

A confirmed infection, such as a urinary tract infection (UTI), is required for a sepsis diagnosis, but must be accompanied by evidence of organ dysfunction, as stated by the Journal of the American Geriatrics Society 3
Organ dysfunction includes hypotension requiring vasopressors, altered mental status, respiratory dysfunction, renal dysfunction, hepatic dysfunction, and coagulopathy, as defined by the World Journal of Emergency Surgery 4
A normal white blood cell (WBC) count does not exclude infection, but significantly reduces the probability of severe bacterial infection, according to the Clinical Infectious Diseases journal 5
The presence of a left shift (bands ≥16% or absolute band count ≥1,500/mm³) has a likelihood ratio of 14.5 for bacterial infection, as reported by the Clinical Infectious Diseases journal 5

A lactate level of 2.1 mmol/L is mildly elevated but well below the 4 mmol/L threshold that historically defined tissue hypoperfusion in sepsis, as stated by the Intensive Care Medicine journal 1, 6
Under current Surviving Sepsis Campaign guidelines, elevated lactate is no longer part of organ dysfunction criteria for defining sepsis, but is used to define septic shock, as defined by the World Journal of Emergency Surgery 4, 2

The appropriate management for a patient with a UTI but no sepsis is to treat the UTI with appropriate antibiotics based on local resistance patterns and urinalysis/culture results, as recommended by the Journal of the American Geriatrics Society and the Clinical Infectious Diseases journal 3, 5
Close monitoring for development of organ dysfunction is necessary, including serial vital signs, mental status changes, urine output, and repeat lactate if clinical deterioration occurs, as stated by the Intensive Care Medicine journal 1, 2
Obtaining a manual differential WBC count to assess for left shift is crucial, as it can increase concern for more severe bacterial infection even with normal total WBC, according to the Clinical Infectious Diseases journal 7, 5
Frequent reassessment (every 4-6 hours initially) is necessary, as clinical status can change rapidly, as recommended by the Intensive Care Medicine journal 2

The Surviving Sepsis Campaign guidelines recommend against using prolactin levels to screen for sepsis, instead focusing on clinical signs of infection and organ dysfunction 8, 9, 10, 11

The American College of Critical Care Medicine recommends measuring lactate levels to identify tissue hypoperfusion in sepsis, with levels ≥4 mmol/L defining sepsis-induced tissue hypoperfusion and requiring immediate protocolized resuscitation 8, 9, 12
Procalcitonin is the biomarker mentioned in sepsis guidelines for assisting in discontinuation of empiric antibiotics in patients who initially appeared septic but have no subsequent evidence of infection 8, 9, 12
Routine screening protocols should focus on clinical signs of infection combined with evidence of organ dysfunction (SOFA score ≥2 points), vital sign abnormalities, and lactate levels 10, 11

Blood cultures should be taken before antimicrobial therapy if no significant delay (<45 minutes) in starting antibiotics 8, 9, 12
The screening algorithm should identify suspected infection based on clinical presentation, assess for organ dysfunction (SOFA ≥2 points), and measure serum lactate immediately 8
If lactate ≥4 mmol/L or persistent hypotension, initiate immediate protocolized resuscitation 8, 9, 12

The Surviving Sepsis Campaign guidelines do not recommend prolactin measurement for sepsis screening, diagnosis, or management 8, 9, 10, 11, 12
Procalcitonin has a role in sepsis management for antibiotic de-escalation, while prolactin has no established role in sepsis screening or management 8, 9, 12