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Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole and joining me today is Dr. Justin Glasgow. He's the associate chief quality officer and physician advisor for sepsis at UAB Medicine. And he's here to talk about the burden of sepsis on our healthcare. Dr. Glasgow. It's a pleasure to have you join us today. I'd like you to start by telling us a little bit about the current state of sepsis today what you've been seeing in the trends, how many people approximately are affected by it each year.

Dr. Justin Glasgow: Yeah, absolutely. Thank you all for inviting me on. And, sepsis is such a large topic that, about 1.7 million cases of sepsis are diagnosed each year. And this leads to nearly 270,000 deaths from sepsis. in the hospital setting, you're looking at about a third of the patients who die in hospital had a case of sepsis, but actually sepsis starting out in the community that makes it such a challenge. As almost 90% of sepsis cases are present when the patient first presents to the hospital.

Melanie Cole: That's interesting. it's a good point. Can you speak a little bit about the etiology and the pathophysiology? The understanding that we know now, maybe we didn't know, 20 years ago of the interplay among the host's immune inflammatory pro coagulants responses in their systems. Tell us a little bit about how that all works and what we know now.

Dr. Justin Glasgow: For everything that we know, there's still a lot that we don't know. But certainly for sepsis, it starts with an infection and, at least we need to believe that there's an infection driving the process underlying everything. And from there. Something leads to actually an overwhelming or sort of dysregulated immune response, which then leads to damage to organs throughout the rest of the body. Sometimes that's the form of increasing the risk and development of clots.

Sometimes it's under profusing the organs and not providing enough oxygen, but we still don't have a really good measure for what it is that leads to that sort of cascade from where the supposed, immune response to an infection is appropriate, to when it becomes too much and then overwhelms the rest of the body.

Melanie Cole: Well, then let's talk about the biggest challenges in diagnostic criteria and the role of accurate sepsis biomarkers to facilitate that diagnosis. And could those be used to enable that timely, appropriate treatment so that it can be started right away and optimize a patient's chance of survival? Speak about what's going on in diagnosis today.

Dr. Justin Glasgow: That is still a big area of development and trying to find the answers. some of the first consensus definitions around sepsis came in the early 1990s, all with the goal of helping develop the research programs that would identify these biomarkers. And we, have things like lactate and procalcitonin, which are associated with infection, might be a sign of a need, but none of them are specific enough to really, be counted on. And so we still work with very broad criteria to of establish a diagnosis of sepsis, which leads to those challenges of either over diagnosing and, giving too many antibiotics or, misdiagnosing because it's broad and everything sort of creates these responses. And you just don't know what is the primary driver until it's too late to recover.

Melanie Cole: So are there some key recommendations for practice and clinical practice guidelines for management? If it's caught in the early stages? Tell us a little bit about that and what antibiotic selection process might look like and how that differs from acute and less acute phases?

Dr. Justin Glasgow: So the, main guidelines that everyone is familiar with come as part of the CMS or Medicare Quality metrics, and is generally known as SEP one. And so it starts with, from the time of recognition of sepsis, expectation to check lactic acid, obtain blood cultures, administer antibiotics. And if the patient is meeting criteria for severe sepsis or septic shock to administer fluids up to or at least 30 CCs per kilogram with some modifications. If you think the patient has heart failure or end stage's renal disease, where that much fluid would be detrimental.

And then depending on that initial result, you would over the next six hours monitor the response to treatment, check follow up lactate, and provide additional care such as initiation of vasopressors if the shock state persists. As far as antibiotics, there has been sort of recent modification to their rules, which used to have two separate criteria, but is now really just getting a good, targeted antibiotic, broad enough, but appropriate for what is the known or suspected infection.

Melanie Cole: So once it's been identified. Dr. Glasgow and completely treated, if that's what happens, what does the deescalation process look like? And what's important for physicians and advanced practice providers to be aware of when they're documenting about sepsis?

Dr. Justin Glasgow: Those initial blood cultures, ideally we're hoping that, comes back to provide us with the organism that is causing the infection and the sepsis. And then, what antibiotics is sensitive to, and the goal is always to get patients to the most, targeted antibiotic, as opposed to broad so that you are treating the one infection you need to, and not having collateral damage from a very broad, antibiotic. Plus decreasing exposure for ongoing antibiotic resistance by using narrow agents. Of course, if those additional studies also show that what you found wasn't due to an infection, but in fact was, maybe a heart failure case, then, it may actually be appropriate to completely stop the antibiotics and then focus your management on those other conditions.

For the documentation, the big thing is to provide as much clarity and specificity in our documents as we can. With sepsis, each organization has a little bit of a variation on what they're documenting in part, because they're currently to come as there are currently two competing consensus views. At UAB, we are doing a bit of a combination of the two in which we maintain the three categories for sepsis, but instead of using this name of severe sepsis, we focus on, is there any organ dysfunction present? So you can document sepsis without organ dysfunction for those Cases that met criteria, but fortunately didn't show signs of organ damage elsewhere in the body.

Or if you did have an acute kidney injury because of the sepsis, you could then say sepsis with acute kidney injury due to, the community acquired pneumonia or whatever it was that we were managing. And then of course the final category of septic shock. Because the final coding and documentation of, the overall hospitalization is done by folks who specialize in that, but not specialize as healthcare providers, being clear when you remove a diagnosis is also important. So we generally recommend that if you have that case where you feel like sepsis didn't drive it. But it was in fact, the heart failure.

Then you would include when you update that diagnosed heart failure, simple statement to say that sepsis was ruled out and then they, everyone sort of knows for clarity that that was what was going through the provider's mind as they did their documentation.

Melanie Cole: That's interesting. So as we get ready to wrap up, what are some of the newest therapies for treating sepsis? Do they sound promising? Let other providers know at other institutions what you're doing at UAB Medicine that they may not know about in your key takeaways from this podcast.

Dr. Justin Glasgow: Sepsis management always comes back to the basics and that is, having it on your differential and thinking about it, anytime you have a change in patient status. Particularly when you have those patients who are very severe and you're thinking about admission or transition to an ICU level of care. As far as, upcoming and specialized, treatments, I'm unaware of anything at the moment that is having a lot of, success. There's few things that are always, considered and the trials around them are fairly equivocal, steroids for the treatment of shock seems to be coming back in terms of identifying the cases where it would be most useful.

But beyond that, there's still lots of work going into figuring out how we better, improve our treatment of sepsis, but not a whole lot that has really established itself as becoming central to our care process. And then I think that leads us with, a few takeaways from this podcast, starting with the summary that sepsis is ever present in patients, particularly in the hospital setting, and the key really is early detection. if there's gonna be the ability to prevent death it's because we have identified and started it early. And so from that point, The second takeaway is if you're thinking sepsis, go ahead and start the bundle, collect the cultures, get the lactate and start antibiotics.

And then third point is you've done that, but that doesn't mean. It stops there. You do have to set back a couple days later and say, okay, what's the overall picture of the patient. Now that we have more information? If we had sepsis and we're managing it and we're doing well, continue that, but narrow in the treatment as much as possible. And of course, if it proves not to be, then let's rule that out and focus our treatment on the actual problems that we identified for the patient.

Melanie Cole: What great information, Dr. Glasgow, thank you so much for joining us today and really telling us about the current state of sepsis and some management guidelines. Thank you again. A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST, or you can visit our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole.