In the beginning, it didn’t seem all that worrisome. Doris Conly’s 89-year-old mother, Yolanda, woke up on a Friday and didn’t feel very well, though she wasn’t in pain — nothing that set off any alarms. Two days later, she couldn’t walk to the car to drive to her doctor, so she was taken to a hospital by ambulance. That Friday, just a week after her initial symptoms, she died from sepsis brought on by a bladder infection. “That’s how fast it happened,” recalls Conly. “My mom was an older woman, but she was in good health, very independent, and saw her doctor for regular checkups. We were in shock.”
Sepsis is a complication that happens when your body tries to fight off an infection, be it pneumonia, a urinary tract infection or something like a gastrointestinal infection. The immune system goes into overdrive, releasing chemicals into the bloodstream to fight the infection. That causes a kind of chain reaction, causing dangerous inflammation throughout the entire body. “Things get out of whack and you end up with something more serious than the infection itself,” says Anthony Fiore, M.D., chief of epidemiology research and innovations at the Centers for Disease Control and Prevention (CDC). Left untreated, sepsis can lead to septic shock, with a drastic drop in blood pressure that can cause heart or respiratory failure, stroke and organ failure.
Sepsis is sneaky — and also deadly. The numbers are eye-opening: According to the CDC, about 1.7 million Americans get sepsis every year, and 270,000 will die from the illness; that’s one person every two minutes. One-third of those who die in a hospital have sepsis. What’s more, says Chirag Choudhary, a critical care physician at Cleveland Clinic and cochair of the medical center’s enterprise sepsis steering committee, “Many of those who survive a sepsis hospitalization are left with a decreased quality of life, with life-changing effects, such as post-traumatic stress disorder, chronic pain and fatigue, organ dysfunction, amputations, and cognitive and functional impairments.” They are also more likely to end up back in the hospital and to have to rely on caregivers.
Serious stuff, to be sure. Yet public awareness of sepsis is low. A 2018 Sepsis Alliance Awareness Survey found that 35 percent of Americans had not heard of sepsis, and the signs and symptoms are not well known outside of health care settings. Consider this your primer to a potentially life-threatening condition.
Anyone can get sepsis, at any age, but older people are most at risk. People over age 65 make up nearly 60 percent of sepsis cases. In fact, sepsis appears to be the most common reason older adults are admitted to an intensive care unit. “As we age, our immune system becomes less effective at fighting infections,” says Choudhary. “And with every infection comes a risk of developing sepsis.” Also, individuals over age 65 are more susceptible to chronic illnesses, which increase the odds of sepsis-triggering infections — the most common being pneumonia, followed by UTIs. “As people age, they may develop cancer, diabetes, kidney disease, heart failure or chronic obstructive pulmonary disease,” says Choudhary. “It’s not unusual to see an elderly person with two or more chronic diseases taking medications to treat these conditions that further suppress the immune system.”
What’s more, infections can be hard to identify in older people, making it a challenge to get a prompt diagnosis and appropriate treatment. For example, fever, the most common sign of sepsis, is absent in approximately 30 to 50 percent of older adults with infections. Another sign of sepsis, mental status, may go unnoticed if a medical team or caregivers aren’t familiar with a patient’s mental status prior to admission. “If a patient comes in confused, with just a little bit of a fever, it’s important to know if that person was playing bridge the day before or if they have already been displaying signs of dementia,” says Fiore. “That can be hard to determine, especially if someone arrives in an ambulance, without accompanying family.” UTIs can also be tricky. The usual symptoms of a urinary tract infection are burning, frequency, urgency or pain. But in older individuals, according to Choudhary, the first sign of a UTI may be a change in mental status. They may become confused or disoriented, so the infection could be present — and left untreated — for a long time before it is noticed.
Beware the breeding grounds
According to the CDC, most cases of sepsis start outside a health care setting, but bedridden patients — particularly those being treated in an intensive care unit or in nursing homes — can be particularly vulnerable. A recent federal report found that care related to sepsis was the most common reason given for transfers of nursing home residents to hospitals, and noted that such cases ended in death “much more often” than hospitalizations for other conditions. In Illinois, about 6,000 nursing home residents a year who were hospitalized had sepsis, and 1 in 5 didn’t survive, according to an analysis by Definitive Healthcare, a private health care data firm.
“There are many infections and antibiotic-resistant infections in these settings and transmission from patient to patient and from health care providers occurs,” says Choudhary. Research has shown that poor hygiene — say, a lack of handwashing or improper handwashing — is the No. 1 cause of people hospital-acquired infection. Health care providers not wearing gloves when providing care and not changing gloves between patients also puts patients at increased risk. Other culprits: pressure sores and exposure to invasive devices, such as catheters and breathing tubes, both a breeding ground for germs and bacteria.
The high rate of sepsis among the older population has consequences for the health care system and is expecting to worsen with an aging population. A CDC evaluation found that 7 in 10 patients with sepsis had recently used health care services or had chronic conditions requiring frequent care. According to a 2016 study from the Healthcare Cost and Utilization Project (HCUP) and the Agency for Healthcare Research and Quality that analyzed billings from 2013, sepsis is responsible for nearly $24 billion in annual costs, making it the most expensive condition to treat in the U.S. health care system.
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Timing is everything
Sepsis ranges from mild to severe, but the earlier you begin treatment, the better the outlook. But “less than 1 percent of Americans can correctly identify the most common symptoms of sepsis,” says Choudhary.
To make things easier, Sepsis Alliance has developed the It’s About TIME campaign, an easily remembered acronym that can aid in recognizing signs of sepsis, while urging the importance of receiving treatment quickly. TIME stands for temperature, infection, mental decline and extremely ill:
- Temperature: Look for a fever of above 101 degrees Fahrenheit or a temperature below 96.8 degrees Fahrenheit, accompanied by shivering or feeling very cold.
- Infection: “Signs include elevated blood sugars in those who have diabetes; wounds, sores or cuts that have redness, are warm to touch [or] painful; or foul-smelling drainage,” says Choudhary. Seek medical help immediately if infections being treated with antibiotics worsen or fail to improve.
- Mental decline: Those with sepsis may seem confused or disoriented, or they might be sleepy or difficult to arouse.
- Extremely ill: Quite simply, feeling extremely ill, be it discomfort or extreme pain, weakness or difficulty breathing.
If you suspect sepsis, it’s important to seek immediate medical attention. “Sepsis must be treated as a medical emergency,” stresses Choudhary. “Death from sepsis increases with every hour that passes before treatment begins.” Physicians diagnose sepsis by evaluating the patient's symptoms and ordering tests, including blood, urine and, if necessary, chest X-ray or CT scan. Next, they'll administer antibiotics to fight the infection. Many patients will also receive oxygen and intravenous fluids to help keep their blood pressure from dropping dangerously low and throwing them into shock, and to help reduce organ damage. If septic shock occurs, other types of treatment, such as kidney dialysis or assisted breathing with a machine, might be necessary. Sometimes surgery is required to remove tissue damaged by the infection.
How to stop sepsis ... before it starts
Prevent infections from happening in the first place by following these tips.
- Keep chronic conditions under control. “People with diabetes, for example, need to keep their glucose within prescribed levels and take care of their skin,” says Fiore. General hygiene is important, too, notes Choudhary: If you’re a diabetic who has a foot infection, such as a chronic foot ulcer, which is common with the disease, be aware of when changes occur and don’t be shy about calling for medical assistance — or at least advice — when you think things are changing.
- Roll up your sleeve. That means staying up-to-date with vaccinations. “A lot of people miss their annual influenza vaccine,” notes Fiore, “And we still have a long way to go when it comes to getting pneumococcal vaccinations up to the recommended coverage among older people.” That’s crucial because pneumonia is the No. 1 cause of sepsis.
- Keep it clean. Ensure that caregivers are doing all they can to prevent infections. “Bedridden patients need to be turned and repositioned every two hours to prevent bed sores, which can turn into infections and pneumonia,” says Choudhary. And make sure they lather up: Lack of handwashing, or improper handwashing, puts people at risk for contracting an infection — likewise, not wearing gloves when providing care and not changing gloves between patients. (It goes without saying that at-home caregivers should follow the same protocol.)
- Be an advocate. Make sure the facility has protocols in place for early recognition and treatment of sepsis, and clue in caregivers about a loved one's medical history. “You probably know them better than the medical personnel or the people caring for them,” says Fiore. “You could be a sort of sentinel as far as alerting the staff to subtle changes that may not show up in the vital signs or might not be obvious during the brief interactions the patient has with their health care providers.”
- Get educated. To learn more, go to survivingsepsis.org, a website maintained by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine. It provides helpful information for sepsis patients and their caregivers.