Includes the essential sepsis sepsis workup,starting from simple tests to more advanced and more specific tests to identify the source of sepsis, and accordingly apply the effective and specific management

1. Sepsis Workup
Dr. Hisham Abid Aldabbagh
MSc. Internal Medicine
Kingdom of Saudi Arabia
Ministry of Health
Directorate of Health
Affairs in Gurayat
Gurayat General Hospital

2. Workup for sepsis may include the following
• Blood and urine studies, including appropriate cultures
• Diagnostic imaging of the chest and abdomen/pelvis
• Cardiac studies such as ECG and cardiac enzymes, as indicated
• Interventions such as paracentesis, thoracentesis, lumbar
puncture, or aspiration of an abscess, as clinically indicated
• Measurement of biomarkers of sepsis such as procalcitonin
levels

3. Laboratory Studies
Complete blood cell count
• A complete blood cell (CBC) count is usually not specific,
because of the numerous conditions that mimic sepsis
and produce leukocytosis with variable degrees of a left
shift. Leukopenia, anemia, and thrombocytopenia may be
observed in sepsis.

4. Blood Culture
• Blood cultures are used to detect the presence
of bacteria or fungi in the blood, to identify the type
present, and to guide treatment.
• Also blood samples may be used to detect viruses
• Susceptibility testing—determines the drug (antimicrobial)
that may be most effective in treating the infection
• Blood cultures are drawn more frequently in newborns and
young children, who may have an infection but may not
have the typical signs and symptoms of sepsis.

5. • Two or more blood cultures that are positive for the
same bacteria or fungi means that the patient tested likely
has a blood infection with that microorganism. The results
typically identify the specific bacteria or fungi causing the
infection.
• If one blood culture set is positive and one set is negative, it
may mean that an infection or skin contaminant is present.
You will consider the patient's clinical status and the type of
bacteria or fungi found before making a diagnosis. Also,
additional testing may be warranted in this case.

6. • Blood culture sets that are negative after several days
(often reported as "no growth") mean that the probability
that a patient has a blood infection caused by bacteria or
fungi is low. If symptoms persist, however, such as a fever
that does not go away, additional testing may be required.

7. • A few reasons that symptoms may not resolve even though
blood culture results are negative may include:
• Some microorganisms are more difficult to grow in culture,
and additional blood cultures using special nutrient media
may be done to try to grow and identify the pathogen.
• Viruses cannot be detected using blood culture bottles
designed to grow bacteria. If you suspects that a viral
infection may be the cause of the patient's symptoms, then
other laboratory tests would need to be performed. The
tests that would be ordered depend upon the patient's
clinical signs and the type of virus suspected to cause the
infection.

8. • Rapid tests are available that can detect several different
types of bacteria that are commonly known to cause
infections of the blood. These tests are used in follow up to
positive blood cultures to quickly identify the bacteria that
are present. They can identify types such as methicillin-
resistant Staphylcoccus aureus (MRSA), which is typically
difficult to treat, and gram negative rods such as E. coli that
live in the gastrointestinal tract. Rapid identification can
facilitate treatment with appropriate antibiotics

9. Bacterial Cultures
• Bacterial culture isolates might suggest the underlying
disease process. Bacteroides fragilis suggests a colonic or
pelvic source, whereas Klebsiella species
or enterococci suggest a gallbladder or urinary tract source.
• If central intravenous (IV) line sepsis is suspected, remove
the line and send the tip for semiquantitative bacterial
culture. If culture of the catheter tip yields positive results
and demonstrates 15 or more colonies and if the isolate
from the tip matches the isolate from the blood culture, an
infection associated with the central IV line is diagnosed.

10. • The rationale for nasal cultures is that nasal colonization
with methicillin-resistant Staphylococcus aureus (MRSA) is
often viewed as a potential marker of subsequent risk for
severe MRSA infection. However, a meta-analysis found
nasal colonization with MRSA to be a poor predictor for the
subsequent occurrence of MRSA lower respiratory tract
infections and MRSA bloodstream infections that require
antimicrobial treatment.. Thus, caution should be exercised
in interpreting nasal cultures in patients in the intensive
care unit (ICU).

11. Urine Culture
• Results of a urine culture are often interpreted in
conjunction with the results of a urinalysis and with regard
to how the sample was collected and whether symptoms
are present. Since some urine samples have the potential to
be contaminated with normal flora from the skin, care must
be taken with interpreting some culture results.
• If a culture is positive, susceptibility testing is typically
performed to guide antimicrobial treatment
• A systematic review found that in adult ICU patients,
catheter-associated urinary tract infection was associated
with significantly higher mortality and a longer stay.

12. • Typically, the presence of a single type of bacteria growing at high
colony counts is considered a positive urine culture. For clean
catch samples that have been properly collected, cultures with
greater than 100,000 colony forming units (CFU)/mL of one type
of bacteria usually indicate infection.
• In some cases, however, there may not be a significantly high
number of bacteria even though an infection is present.
Sometimes lower numbers (1,000 up to 100,000 CFU/mL) may
indicate infection, especially if symptoms are present. Likewise,
for samples collected using a technique that minimizes
contamination, such as a sample collected with a catheter, results
of 1,000 to 100,000 CFU/mL may be considered significant.

13. • A culture that is reported as "no growth in 24 or 48 hours"
usually indicates that there is no infection. If the symptoms
persist, however, a urine culture may be repeated on
another sample to look for the presence of bacteria at
lower colony counts or other microorganisms that may
cause these symptoms.

14. • If a culture shows growth of several different types of
bacteria, then it is likely that the growth is due to
contamination. This is especially true in voided urine samples
if the organisms present include Lactobacillus and/or other
common nonpathogenic vaginal bacteria in women.
• If the symptoms persist, you may request a repeat culture on
a sample that is more carefully collected. However, if one
type of bacteria is present in significantly higher colony
counts than the others, for example, 100,000 CFUs/mL versus
1,000 CFUs/mL, then additional testing may be done to
identify the predominant bacteria

15. Bacterial Wound Culture
• Is ordered to determine whether a wound is infected, to
identify the bacteria causing the infection, and to prepare a
sample for susceptibility testing where required.
• Also be ordered on an individual who has undergone
treatment for a wound infection, to determine whether the
treatment was effective.
• It may also be ordered at intervals on a patient who has
a chronic infection, to help guide further treatment.
• If a fungal infection is suspected, then a fungal culture of the
wound specimen may be ordered along with the bacterial
wound culture.

16. • If pathogenic bacteria are identified in the culture, then it is
likely that they are the source of the infection. An infection
is typically caused by a single type of bacteria, but wounds
may have two or more pathogens
(aerobes and/or anaerobes) that are contributing to the
infection. If more than three organisms are present, they
may not be identified as individual bacterial species and the
report may refer to them as "mixed bacterial flora." This
may indicate a mixture of normal flora and pathogens from
a contaminated sample or from a dirty wound

17. • Very little growth may still be significant, especially when
the wound infection is in an area of the body considered to
be essentially sterile – such as the eye.
• If there are no bacteria recovered in the wound specimen,
then there may not be a bacterial infection, or the
pathogen was not successfully recovered with the sample
and test.

18. • With burn wounds, quantitative culture results may be
requested – the numbers of bacteria that grow are
correlated to the number of bacteria in the infected wound.
When burn tissue specimens have a specific bacterial count
above a certain number, then removal of dead tissue
(debridement) may be indicated.

19. Throat Culture / Strep Throat Test
• This test is ordered when a person has a sore throat and
other symptoms that suggest strep throat. There is a higher
suspicion of strep when the affected person is a child
and/or if the person has been in close contact with
someone who has been diagnosed with strep throat.
• A rapid strep test, also known as a rapid antigen detection
test (RADT), can detect group A strep antigens. Results are
available in 10-20 minutes. If the results of the rapid test
are positive, further testing is not needed and treatment
can be started right away.

20. Bacterial Sputum Culture
• A bacterial sputum culture is ordered when you suspect
that the patient has a bacterial infection of the lungs or
airways, such as bacterial pneumonia or bronchitis
• Sometimes lower respiratory tract infections are caused
by pathogens that cannot be detected with routine
bacterial sputum cultures, so specialized tests may be done
in addition to or instead of a routine culture to help identify
the cause of infection. These additional tests include, for
example, an AFB smear and culture to detect
tuberculosis and non-tuberculous mycobacteria infections,
a fungal culture, or a Legionella culture

21. • Sputum is not sterile, so when a person has an infection,
there will typically be both normal flora and pathogenic
bacteria present. If pathogenic bacteria are identified
during a sputum culture, then antimicrobial susceptibility
testing is usually performed so that the appropriate
antibiotics can be prescribed
• Sometimes a sputum culture may be ordered after
treatment of an infection, to verify its efficacy.

22. CSF Culture
• Obtain a cerebrospinal fluid (CSF) culture before initiating
antibiotic therapy if the child’s condition is stable but
clinical evaluation cannot exclude central nervous system
(CNS) infection.
• Many pathogens can be recovered from CSF cultures
several hours after a dose of antibiotics; thus, a child whose
condition is unstable should receive antibiotics and be
stabilized before lumbar puncture.
• Once the child’s condition is stable, identification of CSF
pleocytosis is helpful, even if prolonged antibiotic therapy
may have rendered culture results negative.

23. • Culture of skin lesions, eye drainage, throat, vagina, rectum,
cellulitic areas, nasal secretions, sputum, tracheal aspirates,
and stool may be helpful in the appropriate clinical context.
• Viral cultures may have a role in certain contexts, although
many viral infections are diagnosed via molecular methods
or serologically.

24. Procalcitonin
• The procalcitonin test is relatively new, but its utilization is
increasing.
• The procalcitonin test has been approved by FDA for use in
conjunction with other laboratory findings and clinical
assessments to assist in the risk assessment of critically ill
people for progression to systemic bacterial infection,or
severe sepsis and septic shock.
• For diagnostic purposes, it is best used during the first day of
presentation. It may be used later on to monitor the response
to treatment.

25. • Procalcitonin may be ordered, along with other tests such
as
CRP, blood culture, CBC, or CSF analysis to help detect or
rule out, distinguish between viral and bacterial meningitis,
or
detect/rule out bacterial pneumonia in those who are
seriously ill and in children with a fever of unknown origin.

26. • Low levels of procalcitonin in a seriously ill person
represent a low risk of sepsis and progression to severe
sepsis and/or septic shock but do not exclude it.
• Low concentrations may indicate a localized infection that
has not yet become systemic or a systemic infection that is
less than six hours old.
• It may also indicate that the patient's symptoms are likely
due to another cause, such as transplant rejection, a
viral infection, or trauma – post-surgery or otherwise.

27. • High levels indicate a high probability of sepsis, that is, a
higher likelihood of a bacterial cause for the symptoms.
They also suggest a higher risk of progression to severe
sepsis and then to septic shock
• Moderate elevations may be due to a non-infectious
condition or due to an early infection and, along with other
findings, should be reviewed carefully.
• Decreasing procalcitonin levels in a person being treated for
a severe bacterial infection indicate a response to therapy.

28. Chest Radiology
Chest radiography is important to rule out pneumonia and diagnose
other causes of pulmonary infiltrates, such as the following:
PneumothoraxPulmonary drug reactions
HydrothoraxPulmonary embolism
Fluid overloadPulmonary hemorrhage
Congestive heart failurePrimary or metastatic pulmonary
neoplasms
Acute myocardial infarctionLymphangitic spread of malignancies
Acute respiratory distress syndromeLarge pleural effusions

29. Abdominal Ultrasonography
• Perform abdominal ultrasonography if biliary tract obstruction
is suspected on the basis of the clinical presentation. However,
abdominal ultrasonography is suboptimal for the detection of
abscesses or perforated hollow organs.
• Ultrasonograms in patients with cholecystitis may show a
thickened gallbladder wall or biliary calculi but no dilatation of
the common bile duct (CBD).
• Stones in the biliary tract are visible in patients with
cholangitis, but the CBD is dilated

30. CT & MRI
• Use CT or MRI of the abdomen if a nonbiliary intra-abdominal
source of infection is suspected on the basis of the history or
physical examination findings. These 2 imaging modalities are
superior to ultrasonography in demonstrating all lesions,
except those related to the biliary tract
• Abdominal CT or MRI is also helpful in delineating intrarenal
and extrarenal pathology. Gallium or indium scanning has no
place in the initial workup of sepsis; patients with sepsis are
acutely ill by definition, and rapid diagnostic tests (eg, CT or
MRI of the abdomen and ultrasonography of the right upper
quadrant) are time-critical, life-saving tools

31. Cardiac Studies
• If an acute MI is likely, perform (ECG) and obtain cardiac
enzyme levels. Remember that certain patients may
present with a silent, asymptomatic MI, which should be
included in the differential diagnosis of otherwise
unexplained fever, leukocytosis, and hypotension. Silent
MIs are common in elderly patients and in those who have
recent undergone abdominal or pelvic surgical procedures.
They are also common in individuals with alcoholism,
diabetes, and uremic conditions

32. Invasive Interventions
• Thoracentesis/paracentesis
• Perform thoracentesis for diagnostic purposes in patients
with substantial pleural effusion. Perform paracentesis in
patients with gross ascites.
• Swan-Ganz catheterization
• Use data obtained via a Swan-Ganz catheter to manage the
fluid status of the patient and to assess left ventricular
dysfunction in patients with acute MI.

33. Sepsis Workup positive Cultures in GGH in the last 3 months
38 patients, 22 male, 16 female; ages: NB11, children 5, adults 12, elderly 10
No.Provisional diagnosisNo.Provisional diagnosis
3DM6ARDS
2Diabetic foot4Wound
1Septic shock4RTA
1Appendicitis4UTI
1ESRD3Pneumonia
1URTI3Abscess
1CVA3Sepsis?

34. Sepsis Workup positive Cultures in GGH in the last 3 months
Blood
15
Urine
13
Wound
10
Sputum
4
Throat
4
Central line
1
Acinetobacter 7 4 2 1 - 1
Klesiella pneumoniae 3 4 2 - 3 -
Staph.hominis 2 - - - - -
MRSA 1 - 4 2 - -
Strepto.epidermidis 1 - - - - -
Proteus mirablis 1 - - - - -
E.coli - 4 1 - -
Pseudomonas
aeruginosa
- 1 1 1 1 -

35. Professional message
Dear colleagues, please
• Fight Against Contamination
• Strict with Infection Control Procedures
• Look Well for the Source of Infection
• Work Together for successful Sepsis Workup

36. Thank you for Sharing in Sepsis Workup
I will be happy to share your action
Email: dr.hishamdabbagh@gmail.com