Sepsis causes 37,000 deaths annually in the UK, a five-fold higher mortality than STEMI or stroke.1 Sepsis is a medical emergency, for every hour antibiotic administration is delayed there is an 8% increase in mortality.2 NICE has published new guidance on recognition, diagnosis and management of severe sepsis.3
A 39-year-old man felt unwell overnight with swelling and pain in his scrotum and penis. In the morning he felt breathless and had blood-stained fluid oozing from his penis. He called 999 and the ambulance crew took him to accident and emergency. The patient admitted that he had not attended earlier because he was frightened and because he was sole guardian of his teenage son, who had to come with him.
The patient was cared for in a cubicle in A&E. As a general practice trainee my first contact with him was when a concerned nursing assistant showed me his ECG, which revealed a sinus tachycardia with a rate of 140bpm.
The patient had no significant medical or sexual history, regular medications or allergies, and his last sexual contact was over two years ago.
Observations showed a respiratory rate of 39 per minute with BP 120/75, oxygen saturations of 97% in air and tympanic temperature of 37.9C. Capillary blood glucose was 13.4mmol/l with no history of diabetes.
The patient’s arterial blood gas showed a marked compensated alkalosis with a lactate 3.9mmol/l. Venous blood results showed a CRP of 535 mg/l, urea of 11 mmol/l and creatinine 200 µmol/l.
|Box 1. Red flags for sepsis in adults1|
Act immediately if ANY ONE of the following are present:
The patient had Fournier’s gangrene. Treatment followed the Sepsis Six care bundle — an initial resuscitation bundle designed for secondary care to offer basic intervention within the first hour of identification (box 2).1
|Box 2. Sepsis Six care bundle1|
Oxygen therapy, IV fluid resuscitation with crystalloid fluid through large bore cannulae, and analgesia were given. Blood cultures were taken. After 95 minutes in A&E the patient was taken to theatre for penile shaft and scrotal skin debridement. After 24 hours he had lower abdominal and thigh incisions. He spent nine days in the high dependency unit.
Guidelines for the management of patients in primary care are shown in box 3.
|Box 3. Guidelines for the management of patients in primary care1|
Sepsis (no red flags):
Red flag sepsis (pending confirmatory tests):
Outcome and follow up
Beta-haemolytic group A streptococcus was identified from the patient’s blood cultures. Antibiotic therapy was guided by the sensitivities.
The patient was followed up in the local plastic surgery department six weeks after leaving hospital for consideration of split skin grafting of unhealed areas.
Healthcare professionals must remain vigilant to the risk of sepsis. It can occur in patients who are expected to be least at risk. In this case, sepsis was only identified when an ECG showed a marked tachycardia in an unassuming young patient.
It is important to triage effectively and review channels of communication so that patients feel able to contact us. The UK Sepsis Trust have produced a useful symptom checker card for patients, which can be downloaded from: sepsistrust.org/uk.
Important: NICE recommends asking 'Could this be sepsis?’ if patients present with signs or symptoms that indicate infection, even if they do not have a high temperature. See NICE algorithm for assessing adults
In Fournier’s gangrene, the infection spreads along well-described fascial planes of the perineum, scrotum and penis, often with involvement of the thighs and lower abdomen.
Fournier’s gangrene fulfils the criteria for necrotising fasciitis; a bacterial infection rapidly spreading through cutaneous tissue planes. Necrotising fasciitis is uncommon, with only 24 patients diagnosed in six years in one tertiary centre (group A streptococcus was the principal organism in a third of these cases).4
The hospital where this patient presented had 17 cases in nine years, of which eight cases related to the pelvic region and thighs.
Since 2001 the Surviving Sepsis Campaign aimed to improve survival. National guidance for hospitals was published in 2005.5
In 2013, the UK Parliamentary and Health Service Ombudsman highlighted shortcomings in initial assessment of patients with sepsis and delay in emergency treatment, which led to missed opportunities to save lives.6
Improvements have been made since then. For example, IT desktop toolkits for GPs are being created by the UK Sepsis Trust.1 NHS England, the Academy of Royal Medical Colleges and the Department of Health are working to reduce avoidable mortality.7
- Dr Sean Brink, GP in East Sussex, United Kingdom
- The UK Sepsis Trust. Toolkit: General Practice management of sepsis. Available from: sepsistrust.org/wp-content/uploads/2015/08/1409322498GPtoolkit2014.pdf
- Kumar A, Roberts D, Wood KE et al. Crit Care Med 2006; 34:1589–96.
- NICE. Sepsis: recognition, diagnosis and early management. NG51. NICE, London, 2016.
- Glass G, Sheil F, Ruston JC, et al. Ann R Coll Surg Engl 2015; 97: 46-51.
- Dellinger RP, Carlet JM, Masur H, et al. Crit Care Med 2004; 32(3):858–73.
- Parliamentary and Health Service Ombudsman. Time to act. Severe sepsis: rapid diagnosis and treatment saves lives. 2013.
- NHS England. Cross-system sepsis programme board. 19 March 2015.