On World Sepsis Day, expert urges: Don’t fear sepsis, treat it early

September 13 was World Sepsis Day, designated by the Global Sepsis Alliance (GSA). It was established to raise awareness of sepsis, a serious global public health issue affecting tens of millions of patients annually, and to increase understanding of the disease.

While efforts to improve awareness of sepsis are underway in academia and other sectors within Korea, the word “sepsis” remains unfamiliar and feared by the general public. To mark World Sepsis Day, Korea Biomedical Review met with Professor Kim Taegyun of the Department of Emergency Medicine at Seoul National University Hospital (SNUH) to discuss the precise definition of sepsis, the importance of diagnosis and treatment, and the challenges facing Korea's management system.

Professor Kim emphasized its curability, saying, “Sepsis is a serious disease, but it is by no means a disease to be given up on. It is a reversible condition that patients can recover from with aggressive treatment.”

Professor Kim Taegyun of the Department of Emergency Medicine at Seoul National University Hospital stressed that sepsis must be treated and can be cured during a recent interview with Korea Biomedical Review. (Courtesy of SNUH)

Q: The disease name ‘sepsis’ is familiar, but it seems the public doesn't accurately understand what it actually is.

A: The Korean translation of the term “sepsis” carries a frightening nuance to the public. Indeed, some patients or their guardians experience significant fear upon hearing the word “sepsis.” While it is a serious disease and treatment can be challenging, it is not an incurable or hopeless condition. It is a fully reversible disease.

Q: We suspect another reason is the difficulty in pinpointing prevention or specific causes.

A: That's right. Defining sepsis was also incredibly difficult. It has been approximately 30 years since the first definition of sepsis was established. At that time, it was defined as “a systemic inflammatory response of the host triggered by infection.” There was another discussion about the definition later, but we still haven't moved beyond that concept. About a decade ago, the “Sepsis-3” definition emerged, changing the concept.

Q: Please explain that concept.

A: Sepsis-3 can be defined as “life-threatening organ dysfunction caused by an uncontrolled host response to infection.” However, sepsis varies greatly in its causes and progression. Even the infectious agents can be different pathogens. The presentation can also vary depending on the anatomical location, such as pneumonia, urinary tract infection, or cholangitis. Furthermore, the definition of sepsis includes an “uncontrolled host immune response,” and immune responses can manifest in various forms. Ultimately, while sepsis can be defined in a single line, its treatment requires individualized, tailored strategies.

Q: Are there specific age groups at higher risk for developing sepsis?

A: Infants and older adults face greater risks. The elderly often have multiple underlying conditions and factors contributing to immune suppression. The mortality rate is generally reported to be around 20-40 percent.

Q: Are there shortcomings in sepsis management in Korea?

A: Korea is considered to have sufficient medical resources and personnel for sepsis management. However, the mortality rate is higher compared to developed countries, suggesting improvements are needed in the sepsis surveillance system and in the adoption of bundle therapies.

Q: We've also heard treatment is difficult.

A: When the “Early Goal-Directed Therapy” algorithm emerged around 25 years ago, it was hailed as a groundbreaking sepsis treatment. However, it has since been largely abandoned, with only a few concepts, such as fluid administration and the use of vasopressors, remaining. No truly innovative treatments have emerged since. Vitamin C and Vitamin B1 briefly gained attention but failed to demonstrate clinical efficacy. Recent efforts have focused on evaluating individual patients' immune states and providing personalized treatment accordingly; however, the results have not been significant.

Q: We've also heard that early diagnosis of sepsis is difficult. What are the reasons?

A: It is not easy to differentiate whether a patient has sepsis or similar clinical symptoms caused by non-infectious conditions. For example, pancreatitis is not caused by infection. Conditions like ischemia-reperfusion injury or severe trauma can also present with symptoms similar to sepsis patients, such as decreased consciousness, fever, hypotension, and elevated white blood cell counts or inflammatory markers, leading to potential misdiagnosis. Distinguishing between infectious and non-infectious causes is quite difficult. This is why early recognition of sepsis is challenging.

Q: Antibiotics are used to treat sepsis. What are the criteria for their use?

A: Antibiotics should be administered within one hour in the initial phase. This applies regardless of whether the cause is infectious or non-infectious. Even if a non-infectious cause is suspected, antibiotics are administered if the patient is in shock or has a poor clinical presentation. The initial selection criteria for these antibiotics are the site of infection. Next, we consider factors like the patient's risk of multidrug-resistant organisms (MDROs). Later, once the causative organism is identified through blood culture tests, we adjust the antibiotics accordingly.

Q: It takes considerable time to identify the causative organism.

A: Typically, broad-spectrum antibiotics are administered initially, so the causative organism is often covered by the antibiotics given early on. Once the causative organism is identified and its antibiotic susceptibility is confirmed, the treatment can be narrowed to a more appropriate antibiotic.

At SNUH, blood cultures follow a maximum five-day incubation period. Recent reports indicate that most causative organisms are identified within four days. In patients with very rapid bacterial growth, bacteremia can occur within hours of the blood culture. If bacteremia is confirmed, bacterial identification and antimicrobial susceptibility testing are performed immediately to rapidly select the appropriate antibiotic.

Q: The faster the blood culture results, the better the treatment outcome?

A: That's correct. It benefits the patient’s prognosis in two ways. First, accurately identifying the causative pathogen enables the switch from broad-spectrum antibiotics to narrower-spectrum ones. This prevents resistant bacteria from emerging and reduces disruption to the gut microbiota. It also enables rapid antibiotic change if the initial choice proves ineffective.

Q: What aspects of Korea’s sepsis system require improvement?

A: In healthcare institutions with limited resources, surveillance systems for early sepsis recognition are often inadequate, and the implementation rate of early bundled therapy is inevitably low. Improvements in these areas are necessary.

Q: Preventing sepsis also seems challenging.

A: It is quite difficult. Nevertheless, efforts must be made to minimize the occurrence of infections and ensure more aggressive treatment when infections occur. Basic hygiene practices in daily life, such as handwashing, are crucial. Healthcare providers must also be cautious about the overuse of antibiotics to reduce the emergence of resistant bacteria. While there is no vaccine that directly prevents sepsis, adhering to the national recommended essential vaccinations can help prevent infections.

Q: Regarding sepsis, what would you remind frontline medical workers?

A: Early recognition is crucial. Departments less frequently exposed to sepsis may struggle with early detection. In such cases, delays in implementing the one-hour bundle of care can adversely affect prognosis. Therefore, it is essential to educate medical staff on the concept of sepsis, including its definition and diagnostic criteria.

Improving public awareness is also vital. When patients or guardians first hear the term “sepsis,” reactions like “Doesn't that mean death?” sometimes occur. Such misunderstandings can negatively impact treatment. While sepsis has a high mortality rate, it is also a highly reversible condition. Rarely, patients or families give up on treatment prematurely out of fear, assuming it will be too difficult, even when aggressive treatment is warranted.

Q: What does it mean to give up on treatment?

A: Sepsis can lead to multiple organ failure. For example, respiratory failure may require a ventilator, and impaired kidney function might necessitate dialysis. Occasionally, patients refuse these treatments. Of course, for patients in the terminal stage, those without the physical strength to endure such treatments, or those for whom treatment is expected to worsen their underlying condition, there is room to consider options. However, it's truly heartbreaking when relatively young patients, or those for whom treatment clearly offers the potential for a good outcome, refuse treatment.