Stuart Snape, Managing Partner, Graham Coffey & Co. Solicitors, walks us through what the COVID-19 pandemic has taught us about the need for urgent sepsis care
We are in the midst of a global pandemic. We are told we face a once in a generation threat to our very existence. Never before has there been such an outpouring of faith, respect and gratitude to our care workers and rightly so. But whilst COVID-19 strikes at the very heart of our society, are we guilty of ignoring a similar threat that has caused untold misery for millions often under the cloak of ignorance – sepsis.
Sepsis is not in itself an infection or disease. It is the abnormal body response to infection. In most cases, the immune system will protect from the many dangers posed by sepsis, however, for some, the immune system can go into overdrive, releasing chemicals into the bloodstream, which can cause inflammation and — if untreated —tissue damage, organ failure and death. In many cases of sepsis, it is the immune system’s response that is often more dangerous than the infection itself.
The Global Sepsis Alliance has confirmed that COVID-19 can itself lead to sepsis, providing a stark example of how, in some cases, the body’s own response to infection can be the cause of complications and a high risk of mortality.
Taking sepsis seriously
In May 2017, The World Health Organization (WHO) mandated that all Member States must have a national plan to deal with sepsis, such is the threat it presents.
One of the most recent studies into sepsis-related deaths confirmed that in 2017 alone there were almost 50 million sepsis cases worldwide and approximately 11million deaths.
The illness causes more deaths than bowel, breast and prostate cancer, and yet the lack of publicity and information surrounding sepsis stands in stark contrast to the huge public health campaign that has followed the COVID-19 pandemic, and the aforementioned cancers.
Getting an early diagnosis of sepsis is vital. However, what makes this particularly difficult is that for many patients the first signs of sepsis will display whilst at home. Typical symptoms can include confusion, slurred speech and breathlessness and herein lies the difficulty. For many who are already suffering from an illness or an infection, some of these symptoms may have already been present, or they may consider the additional symptoms to simply be a worsening of their existing condition.
This is why educating the public is essential. As the world began to recognise the danger posed by sepsis, many countries began to step up their public awareness campaigns. The UK launching their action plan in 2015 and the U.S. work by groups such as the Sepsis Alliance made huge progress as far back as 2011 including designating September as Sepsis Awareness Month.
Spotting the signs
Identifying sepsis is not only difficult for the general public, but it has also proven a huge challenge for clinicians within the medical setting. Patients arriving at Accident and Emergency have proven particularly vulnerable to misdiagnosis.
Reasons for misdiagnosis can be varied, but it is true to say that as health systems around the world have sought to improve awareness among the general public, they have also sought to improve education among clinicians and health workers.
Risk assessments and treatment pathways are intended to ensure that the risk of sepsis is front and centre when assessing patients have rapidly moved to the forefront of clinical practice. There is an ever-increasing use of technology and science to help speed up the clinical diagnosis of sepsis, but at the forefront of that is the need to identify sepsis as a risk at the very start.
In the UK, the National Institute of Clinical Excellence introduced guidance in 2016, which has been regularly updated since, that sought to place sepsis as a primary consideration when treating patients who present with possible infection. It very much worked on the basis that if it could be sepsis then presume it is that until you can be sure it is not.
Further issues
It would be wrong to presume that the real danger posed by sepsis is all down to lack of education or delayed diagnosis.
To treat sepsis, you have to be able to treat the underlying cause of infection as quickly as possible. This inevitably leads to friction between the need to commence treatment early and the long-standing fundamental principles of safe and appropriate antimicrobial prescribing.
The early management of sepsis requires administration of antibiotics within an hour of patient presentation. There is a risk that with increased awareness of sepsis, undisciplined use of antibiotics will increase and antimicrobial resistance will get worse.
Antimicrobial resistance has been identified by the WHO as a global threat and identifies the misuse and overuse of antimicrobials as accelerating this process. This applies to both use by humans, but also animals.
In fact, the risk of antimicrobial-resistant infections was identified as a significant risk as long ago as 1945 by Alexander Fleming, who pronounced during his Nobel Lecture: “The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”
Dr Liz Taylor of the WHO estimated the number of deaths per year directly caused by AMR by 2050 could be as high as ten million and the possible costs to the world’s economy from the risk of AMR could be as high as one trillion dollars.
As antimicrobial-resistant microbes spread so the importance of hygiene, sanitary conditions and food hygiene become a matter of life and death.
The WHO has been increasing their focus on IPC – infection prevention and control.
This brings us full circle to the current situation we find ourselves in. A global pandemic caused by a virus with no known cure. As with all such infections the most important defence is to avoid the infection in the first place. There is unlikely to be many people who have not heard the recent advice to wash hands.
Sepsis continues to lurk in the shadows, and as our ability to treat the cause of the original infection decreases so the dangers of sepsis become more acute.
What has been underlined by this current COVID-19 crisis is that borders are of no relevance. There is no place for national agendas or protectionism. This is a worldwide problem which will require a worldwide solution which will inevitably be underpinned by a worldwide understanding of the importance of washing our hands.
