who present increased risk
of poor response to treatment.
Although this score system can be
easily applied at the pre-hospitalisation
stage, as for other currently used scores it is
often not enough to diagnose sepsis and its
associated conditions in a timely manner,
requiring additional time-consuming laboratory
investigations. 4
Early-stage screening of sepsis and septic shock
may include tools and protocols to identify
suspected cases, as well as computer-assisted
algorithms to alert health care professionals,
automated orders for laboratory tests, and use of
biomarkers. Ideally such screening tools should
be inexpensive and easy to use, be able to
consistently identify septic conditions, and
obviously result in improved outcomes for
patients. Nonetheless, the diagnostic accuracy
of these tools must be thoroughly assessed and
validated before being widely implemented in
health care units, and further studies are needed
to evaluate their impact on the early recognition
of these critical conditions and the speed and
quality of conventional treatments.
infection, the specific
clinical context, recent
antibiotic use, and the
microbial resistance profiles
typical of the region, but these drugs are often
overprescribed and may not adequate for the
causative pathogen(s). 4 For this reason, tools
to identify suspected cases of sepsis are of
utmost importance in the context of septic
conditions.
Screening tools for identification
of patients at risk
As for other serious medical emergency
conditions such as stroke and severe trauma,
warning score systems specifically validated for
the prediction of outcomes have been used in
clinical practice at different stages to identify
patients at risk of developing sepsis and septic
shock. 4 These predictive scores for sepsis are
mostly based on the patient’s demographic
characteristics and the condition’s clinical and
analytical variables, and have demonstrated
variable degrees of effectiveness relative to
clinical judgment alone. 7
Traditionally, the diagnosis of septic conditions
has relied on the assessment of the clinical signs
of systemic inflammatory response syndrome
(SIRS) − namely heart rate, respiratory rate,
temperature, and white blood cell counts
− together with the analysis of metabolites and
biomarkers such as lactate, procalcitonin, and
C-reactive protein. 8 More recently, the SSC task
force recommended the use of the quick SOFA
(qSOFA) score to trigger the investigation of organ
dysfunction and initiation or escalation of
therapy. 4 qSOFA uses three criteria: assigning one
point for low blood pressure (SBP≤100mmHg),
high respiratory rate (≥22 breaths per min), or
altered mental status (Glasgow coma scale <15).
A prospective cohort study conducted in Europe
evaluated the qSOFA system among patients with
suspected infection admitted to the emergency
department and showed a favorable prognostic
accuracy of in-hospital mortality compared to the
use of SIRS criteria. 9 However, a recent meta-
analysis of observational studies evaluating the
accuracy of qSOFA to predict mortality in patients
with suspected or proven infection revealed that
this tool has overall low sensitivity as a predictive
marker of mortality in the hospital setting. 10
In addition to qSOFA, other parameters have
been evaluated as predictors of patient
Early identification and intervention
Early identification and intervention have long
been recognised as fundamental factors for
reducing the risk of death among patients with
sepsis and septic shock, as well as for reducing
severity scores and organ dysfunction, prior to
admission to the intensive care unit. 5 Recognition
of suspected sepsis in the first six hours of
admission, followed by goal-directed therapy
involving cardiopulmonary resuscitation with the
aim to restore tissue perfusion, significantly
decreases in-hospital mortality when compared
to standard approaches. Although prompt
administration of the appropriate intravenous
fluids and antibiotics can undoubtedly improve
clinical outcomes, these should be given within
one hour of suspicion of sepsis. 6
Sepsis Six
With this need for timely recognition and action
in mind, the UK Sepsis Trust developed the Sepsis
Six bundle, which addresses assessment and
initial resuscitation as well as risk stratification,
with the objective to be implemented within one
hour of recognition of sepsis by a health care
professional at the hospital. Empirical antibiotic
therapy is established according to the source of
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