Sepsis: from a flame can arise a pyre needed early and coordinated interventions. Tuscan region leader in the struggle
(by Nicola Simonetti and Donatella Tansella) Sepsi: a stake of the organism. The arsonist, a little thing - microbe - invisible to the naked eye, lights a flame from which the fire blazes. And it is immediately an emergency, a risk of total involvement and, even, of definitive destruction.
But, when it does not kill (three out of 10 die immediately or within a year), sepsis - says prof. Sabino Scolletta, director of resuscitation and critical medicine az. Siena University Hospital - leaves the marks of its passage: scars, almost always disfiguring, and, in 2 out of ten, serious disorders that include important functional and cognitive limitations. One in five people hospitalized for sepsis, however, needs a new hospitalization within one month of discharge.
Historical figures such as Lucrezia Borgia, Francesco I of Valois, Ferdinand II and many other titled or anonymous citizens who are victims of this devastation could tell it, today, despite the available means, affects millions of people every year in the world, and 30 kills 7-9 million (in Italy, 34.000).
Italy is lagging behind in number of cases and deaths from sepsis in Europe (dat Global Sepsis Alliance). But there is a "happy" island - Tuscany, where an Operational Plan was formulated that teaches: on the occasion of World Sepsis Day, an operational plan ("Cell to Action"), a document that teaches: a job team result of the contribution of professionals from different backgrounds, with the coordination of the Regional Clinical Risk Management Center and the Regional Health Agency.
Sepsis is caused by an unregulated response to an infection by the immune system which, instead of reacting against invading microorganisms, attacks the organism itself, also damaging organs and tissues that are not the site of primary infection. This is a serious complication that endangers life within a few hours. For this reason it can be defined as a time-dependent pathology, like stroke or myocardial infarction, and imposes a rapid health response that requires an equally timely and above all accurate diagnosis. The time factor and the role of microbiology are fundamental for an adequate health response that must be interdisciplinary and integrated.
Poor hygiene, inappropriate use of antibiotics, inadequate compliance with recommended vaccinations, recognition and deferred treatment over time represent as many "pokes fire" to fight and avoid.
"This pathology - says Fabrizio Gemmi, coordinator of the ARS Toscana Quality and Equity Observatory - affects about 1,8 percent of patients hospitalized in Tuscany, with an incidence of 261 patients per 100.000 inhabitants".
"Precisely due to the fact that the risk of sepsis is multifactorial, the underlying guiding principle of our Call to Action guideline document was to promote awareness of the problem in all sectors of the Health Services involved, from counseling to territorial emergency and basic medicine. It is then necessary to ensure - he adds - declared Giulio Toccafondi, Clinical Risk and Patient Safety Management Center, Tuscany Region - that, once a case of sepsis has been identified, the resources of the health system operate in synergy and in an integrated way, through the competition. more professionals, who gather around the patient's bed, going beyond the usual routine of the single department ".
The role of laboratories and microbiology is also central. "Blood culture is the fundamental microbiological investigation to identify bacteria that may be present in the blood. For a rapid diagnostic orientation there are also biomarkers and, today, rapid microbiology methods are available ("fast microbiology"), which greatly shorten the time of diagnosis and allow the identification of bacteria awaiting the outcome of blood culture, verifying if they are carriers of resistance against the most used antibiotics. Information, the latter, extremely valuable because, pending the antibiogram, it allows defining the correct and personalized antibiotic therapy, whose precocity is decisive for the prognosis "(prof. Gian Maria Rossolini, university, Florence).
In summary it can be stated that:
- about 70% of clinical decisions are guided by laboratory tests: for this reason it is very important to be able to count on reliable, fast and high quality results
- microbiological tests performed promptly and without a margin of error are essential to identify targeted therapy, improving the patient's chances of recovery and reducing the risk of inappropriate use of antibiotics
- if the microbiology laboratories do not meet the best organizational and technological standards available, the results may not be reliable, putting at risk the beginning of a correct therapy
- to ensure that the laboratories meet the necessary quality standards, we must focus on reorganizing the laboratories in order to make the best use of the most advanced diagnostic technologies in new and improved processes; in this sense, automation can be an advantage, guaranteeing complete traceability of samples, from acceptance through to the final report and simplification of complex processes, with faster response times
In the last published report, related to the 2018 (downloadable from the link http://www.giviti.marionegri.it/Download/ReportPetaloInfezioni_2018_IT_TIPolivalenti.pdf), the data of the 37.926 patients admitted in the 118 intensive care departments who have adhered to the project: of these 12.609 they developed infections, in 19,6% of cases without sepsis, in 51,4% complicated by sepsis and in the remaining 29% by septic shock. Intensive mortality for sepsis and septic shock was 18,4% and 46,1% respectively.
The Tuscany Region's effort is to create a Sepsis Observatory with data taken from hospital discharge records (SDOs) and therefore from all hospital departments, compiled with a correct coding of sepsis and septic shock. The creation by the National Institute of Health of a National Observatory of Sepsis and Septic Shock is therefore fundamental.