Candel F J, Borges Sá M, Belda S, Bou G, Del Pozo J L, Estrada O, Ferrer R, González Del Castillo J, Julián-Jiménez A, Martín-Loeches I, Maseda E, Matesanz M, Ramírez P, Ramos J T, Rello J, Suberviola B, Suárez de la Rica A, Vidal P
Francisco Javier Candel González, Department of Clinical Microbiology. Hospital Clínico San Carlos. IdISSC Health Research Institute Universidad Complutense. Madrid. Spain. Avda Profesor Martín Lagos s/n. 28040.
Rev Esp Quimioter. 2018 Aug;31(4):298-315. Epub 2018 Jun 25.
The incidence and prevalence of sepsis depend on the definitions and records that we use and we may be underestimating their impact. Up to 60% of the cases come from the community and in 30-60% we obtain microbiological information. Sometimes its presentation is ambiguous and there may be a delay in its detection, especially in the fragile population. Procalcitonin is the most validated biomarker for bacterial sepsis and the one that best discriminates the non-infectious cause. Presepsin and pro-adrenomedullin are useful for early diagnosis, risk stratification and prognosis in septic patients. The combination of biomarkers is even more useful to clarify an infectious cause than any isolated biomarker. Resuscitation with artificial colloids has worse results than crystalloids, especially in patients with renal insufficiency. The combination of saline solution and balanced crystalloids is associated with a better prognosis. Albumin is only recommended in patients who require a large volume of fluids. The modern molecular methods on the direct sample or the identification by MALDI-TOF on positive blood culture have helped to shorten the response times in diagnosis, to optimize the antibiotic treatment and to facilitate stewardship programs. The hemodynamic response in neonates and children is different from that in adults. In neonatal sepsis, persistent pulmonary hypertension leads to an increase in right ventricular afterload and heart failure with hepatomegaly. Hypotension, poor cardiac output with elevated systemic vascular resistance (cold shock) is often a terminal sign in septic shock. Developing ultra-fast Point-of-Care tests (less than 30 minutes), implementing technologies based on omics, big data or massive sequencing or restoring "healthy" microbiomes in critical patients after treatment are the main focuses of research in sepsis. The main benefits of establishing a sepsis code are to decrease the time to achieve diagnosis and treatment, improve organization, unify criteria, promote teamwork to achieve common goals, increase participation, motivation and satisfaction among team members, and reduce costs.
脓毒症的发病率和患病率取决于我们所采用的定义和记录方式，其影响可能被低估。高达60%的病例来自社区，其中30%-60%的病例可获取微生物学信息。有时其表现不明确，检测可能会延迟，尤其是在脆弱人群中。降钙素原是用于细菌性脓毒症最有效的生物标志物，也是区分非感染性病因的最佳标志物。可溶性髓系细胞触发受体-1和前肾上腺髓质素对脓毒症患者的早期诊断、风险分层及预后评估很有用。生物标志物联合使用比任何单一生物标志物在明确感染病因方面更有用。使用人工胶体进行复苏的效果比晶体液差，尤其是在肾功能不全患者中。生理盐水与平衡晶体液联合使用与更好的预后相关。白蛋白仅推荐用于需要大量补液的患者。直接样本上的现代分子方法或阳性血培养中基质辅助激光解吸电离飞行时间质谱鉴定有助于缩短诊断反应时间、优化抗生素治疗并促进管理计划。新生儿和儿童的血流动力学反应与成人不同。在新生儿脓毒症中，持续性肺动脉高压导致右心室后负荷增加及心力衰竭伴肝肿大。低血压、心输出量低伴全身血管阻力升高（冷休克）往往是脓毒症休克的终末体征。开发超快速即时检测（不到30分钟）、实施基于组学、大数据或大规模测序的技术或在治疗后恢复危重症患者的“健康”微生物群是脓毒症研究的主要重点。设立脓毒症代码的主要益处在于缩短诊断和治疗时间、改善组织、统一标准、促进团队合作以实现共同目标、提高团队成员的参与度、积极性和满意度并降低成本。
