A Study On Clinical Profile of Sepsis Patients in Intensive Care Unit of A Tertiary Care Government Hospital in North East India

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Volume 1, Issue 3, Mar 2017 Available at: www.dbpublications.org
International e-Journal For Medical And Research-2017
A Study On Clinical Profile Of Sepsis

Patients In Intensive Care Unit Of A
Tertiary Care Government Hospital In North
East India
Dr DEEPAK CHAUDHURY1, Dr CHANDRAPRAKASH 2 , Dr
SUBHANKAR PAUL 3 , Dr ILIAS ALI4
1: Assistant professor, 2: Former post Graduate Trainee, 3: Post Graduate Trainee , 4: Professor &
Head,Department of Emergency Medicine , Gauhati Medical College & Hospital , Guwahati, Asaam
ABSTRACT required dialysis. Gram negative bacteria

were found to be the predominant
Background : Sepsis is life-threatening pathogens associated with sepsis(73.4%)
organ dysfunction caused by a where most common organism responsible
dysregulated host response to infection was Klebsiella (36.8%).
which is one of the most important cause
of mortality & morbidity in critically ill Conclusion : assessment of clinical signs
patients. In this study clinical profiles of & initial serological & radiological
the sepsis patients admitted in ICU in this investigations are of utmost importance to
part of India have been evaluated. detect more critically ill patients as early
as possible to intervene earlier for saving
Methods & Materials: This prospective the life of the sepsis patients.
hospital based observational study was
undertaken in the department of KEYWORDS: SEPSIS, MODS,
Emergency Medicine ICU of Gauhati SPECIMEN CULTURE, SOFA,
Medical College & Hospital, over a period APACHE
of one year from August 2014 to July 2015
after obtaining institutional ethical INTRODUCTION
committee clearance.
Sepsis is the primary cause of death from
RESULTS: Clinical profiles of 50sepsis infection despite advances in modern
patients, with male preponderance (56%) medicine, including antibiotics, vaccines,
& mortality rate 36% were studied. Mean and intensive care. Globally, an estimated
age was 48.36 years (SD 17.16). fever & 20 30 million cases of sepsis occurs each
tachycardia were present in all patients. 30 year. Every hour, about 50 people die from
patients (60%) required ventilatory sepsis (1) & Patients surviving sepsis
support, 28 patients (56%) required have double the risk of death in the
inotropic support, 10 patients (20%) following 5 years compared with
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hospitalized controls and suffer from were included in the study. However
physical, cognitive and affective health Patients with Pregnancy , primarily
problems (2) . suffering from Pancreatitis , adrenal
insufficiency , Burns, Pulmonary
Sepsis is often diagnosed too late, because embolism, Cardiac tamponade, Tumor-
the clinical sign-symptoms and laboratory associated lactic acidosis, drug overdose &
parameters that are currently in use for the anaphylaxis, on treatment with
diagnosis of sepsis eg. raised temperature, immunosuppressive agents were excluded
increased heart-rate or breathing rate, or from the study. The detailed history,
white blood cell count, are non-specific. In clinical examination and all the relevant
children, the signs and symptoms may be laboratory investigations were done. All
subtle and deterioration rapid. Sepsis is the patients of sepsis admitted to
poorly understood and under-recognized emergency ICU were prognosticated on
due to confusion about its definition the basis of APACHE II score and SOFA
among patients and healthcare providers, score. APACHE II was calculated on day
lack of documentation of sepsis as a cause of admission to predict mortality & to
of death in death-certificates, inadequate assess the extent of multi-organ
diagnostic tools, and inconsistent dysfunction daily SOFA scoring was
application of standardized clinical done. We have analyzed various profiles
guidelines to diagnose & treat sepsis (3) . between two groups, survivor group which
Cultures and serology reports are available include the patients who were successfully
mostly after 24 to 48 hours. In the crucial discharged after recovery and non-survivor
hours which determine the prognosis of group which include the patients who died
the patient the physician has to depend on .
clinical symptoms and demographic data Statistical Methods
to aid in diagnosis and management.
Hence our study was performed with a Descriptive and inferential statistical
view to have an insight of the clinical analysis has been carried out in the present
profile of septic patients in the ICU so as study. Results on continuous
to diagnose, prognosticate & intervene measurements are presented on MeanSD
earlier. (Min-Max) and results on categorical
measurements are presented in Number
MATERIALS & METHODS (%). Significance is assessed at 5% level
of significance. Student t test (two-tailed,
This prospective hospital based
independent) has been used to find the
observational study was undertaken in the
significance of study parameters on
department of Emergency Medicine ICU
continuous scale between two groups Inter
of Gauhati Medical College & Hospital,
group analysis) on metric parameters. Chi-
over a period of one year from August
square/Fisher Exact test has been used to
2014 to July 2015 with prior approval
find the significance of study parameters
obtained from Institutional Ethical
on categorical scale between two or more
Committee . The patients with sepsis ,as
groups. All data were analyzed with SPSS
defined by the American College of Chest
16.0 Microsoft word 10.0 and Excel have
Physicians/Society of Critical Care
been used to generate graphs & tables.
Medicine (ACCP/SCCM) Consensus
Committee in 1992 , above 18years of age Results & observations

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After applying the inclusion & exclusion
criteria , clinical profiles of 50 patients
with sepsis were studied, out of which 28
were male(56%) and 22 were The commonest symptom in our
females(44%). 18 patients( 36%) died and study population was fever in 50 patients
32 patients (64%) survived in this study. (100%) followed by breathlessness (16,
Age of patients varied from 18 years to 90 32%), decreased urine output (16, 32%) ,
years, with mean 48.36 years (SD 17.16). abdominal pain (16, 32%) vomiting (12,
Highest numbers of cases were seen the 24 %) etc. All patients had temperature
age group of 61 to 70 years i.e. 12 patients above 1000 F and pulse rate above 100
(24%) followed by 41 to 50 years in 10 beats per minute. 20 patients(40%) had
cases (20%), 21 to 30 years in 9 cases blood pressure less than 90/60 mm Hg ,
(18%) (Fig 1). Youngest patient in the Tachypnea 43 (86 %) , Altered mental
study is 18 years old. Oldest patient is 90 status 17 (34 %). Out of 50 patients, 30
years patients (60%) required ventilatory
support, 28 patients (56%) required
Fig 1 : Bar diagram showing Age inotropic support, 10 patients (20%)
distribution of study population required dialysis. Duration of ICU stay
was less than 7 days in 44 patients.
On admisssion 16 patients (32%)
had anemia, leucocytosis in 38 (76%)
patients & Leucopenia in 4patients (8%),
38 patients (76%) had hyponatremia
(Na<135meq/l) , 13 patients (26%) had
hypokalemia (K <3.5meq/l) and 4 patients
(8%) had hyperkalemia (>5.5), 41 patients
24 patients (48%) patients had associated co- (82%) had acidic pH( <7.35) on the day of
morbidities , with diabetes being commonest admission.
of them (n=14, 28%) (Fig 2) .
Furthermore , our study catered to the
Fig 2: Pie diagram showing distribution of comparison of clinic-pathological
existing co-morbidities in sepsis patients parameters in survivor & non-survivor
group as shown in Table 1& 2.
Diabetes
28%
52%
Hypertensi
20%
on
2% 4%

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Table 1: Comparison of symptoms & clinical parameters in survivors and non-
survivors of patients
Surviv
ed
Non-survived (n=
Variables (n=18) 32) p value
Age in years (mean SD) 51.0619.59 46.8415.77 0.411
Fever (no, %) 18, 100.0 % 32, 100.0 % 1.000
Headache (no, %) 2, 11.1 % 2, 6.2 % 0.612
Cough (no, %) 5, 27.8 % 8, 25.0 % 1.000
Breathlessness (no, %) 7, 38.9 % 9, 28.1 % 0.532
Altered Sensorium (no, %) 1, 5.6 % 1, 3.1 % 1.000
Vomiting (no, %) 4, 22.2 % 8, 25.0 % 1.000
Jaundice (no, %) 2, 11.1 % 2, 6.2 % 0.612
Oliguria (no, %) 4, 22.2 % 12, 37.5 % 1.000
Abdominal Pain (no, %) 5, 27.8 % 12, 37.5 % 1.000
Chest pain (no, %) 2, 11.1 % 3, 9.3 % 1.000
Loose stools (no, %) 2, 11.1 % 3, 9.3 % 1.000
Temperature (mean SD) 102.481.06 102.611.01 0.658
Pulse rate (mean SD) 123.4413.51 117.635.04 0.033*
GCS 10.065.57 14.191.99 <0.001*
Respiratory rate (mean SD) 27.225.54 26.55.47 0.658
APACHE II score DAY1 23.289.65 18.757.34 0.068
Ventilator support (no, %) 16(88.9%) 14(43.8%) 0.002*
Inotropic support (no, %) 13(72.2%) 15(46.9%) 0.083
Dialysis (no, %) 2(11.1%) 8(25.0%) 0.295
Duration of ICU stay (no, %) 3.723.08 3.752.02 0.969
Table 2: comparison of biochemical parameters with survivors and non survivors of

patients studied
Variables Non-survived Survived p value
Hemoglobin 11.144.02 10.892.04 0.770
Haematocrit 37.549.67 38.584.39 0.605
Total count 15827.788423.69 22893.7524048.53 0.236
Serum sodium 132.834.79 130.533.92 0.072
Serum potassium 4.240.67 3.960.85 0.236
PH 7.240.13 7.240.1 0.989

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Serum bilirubin 2.191.41 2.782.55 0.375
Serum amylase 20.5611.55 17.695.97 0.251
Serum Creatinine(mg/dl) 1.761.06 2.772.43
SOFA score was significantly low especially on day 3 (6.842.96) in survivor group as
compared to non survivor group whose mean day 3 value being (13.424.060) (Table 3).
Table 3: Evaluation of SOFA score in survivors and non survivors patients
SOFA score Non survived Survived p value

Day 1 10.173.45 7.942.64 0.014*
Day 2 11.634.33 8.282.62 0.002**
Day 3 13.424.06 6.842.96 <0.001**
Day 4 10.783.77 5.943.41 0.001**
Day 5 12.254.8 4.553.27 <0.001**
Day 6 12.296.1 3.392.77 <0.001**
Day 7 14.23.9 2.822.61 <0.001**
Day 8 133.39 2.452.5 <0.001**
Day 9 13.84.09 1.811.72 <0.001**
Day 10/last day 13.55.69 1.331.23 <0.001**
Definite microbiological evidence Fig 3: Bar diagram showing culture

of infection was found in 56% of patients positivity in patients of sepsis
with sepsis in ICU (28 of 50) (from
culture of appropriate specimens and 40% 38%
blood culture). culture of appropriate
30% appropriate
patients (%)
specimen ( as determined from history

and clinical examination ) , eg sputum, 18% culture
20%
urine, stool, pus, asctic or pleural fluid etc Blood cultue
could identify a definite microorganism in 10% positive
38% patient of sepsis whereas Blood
culture was positive in only 18% of cases 0%
of sepsis. ( Fig 3).

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Table 4: microorganisms associated with sepsis (from appropriate specimen culture )
Appropriate specimen Culture Blood Culture positive

Type of pathogen
positive (n= 19) (n=9)
Klebsiella 7(36.8%) 2 (22.2%)
Pseudomonas 5(26.3%) 3 (33.3%)
E. Coli 2(10.5%) 2 (22.2 %)
Staph aureas 2 (10.5%) 1(11.1%)
Enterococcus 1(5.2%) 1 (11.1%)
Polymicrobial 1 (5.2%) -
Others - 1(5.2%)
Table 4 shows that Gram negative bacteria females in this cohort and mean age of
were found to be the predominant 48.3years. Similar study in India have also
pathogens associated with sepsis(73.4%). shown male preponderance with most
The most common organism responsible patients in the fourth to fifth decade.4
for sepsis was Klebsiella (36.8%), All patients had fever with breathlessness
followed by Pseudomonas (26.3%), Staph and oliguria being the next predominant
aureas and E. coli(10.5%) both. However, symptom observed in 32% patients each.
Pseudomonas was the most common Among the several disorders encountered in
organism isolated from blood culture sepsis, acute kidney injury (AKI) mostly
followed by Klebsiella. manifested clinically by decreased urine
output, is one of the most important because
Discussion it is a life-threatening condition, increases
The clinical profile of 50 patients with the complexity and cost of care, and is an
sepsis was studied with 28 males and 22 independent risk factor for mortality. 5,6 .

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There was no significant difference in predictor of mortality.
symptomatology between survivors & non- Many studies have shown that high
survivors. APACHE II score at the time of admission
was associated with high mortality 6 . In this
The mean SOFA score on the day of study, though mean APACHE II score was
admission was 8.74 and the mean APACHE high among non-survivors than survivors
II score on the day of admission was 20.14 (23.28 v/s 18.75), but it was of no statistical
suggesting there was significant organ significance.
dysfunction in all patients. In our study, 30 SOFA score has been validated extensively
patients (60%) required ventilator support, for prognostification. In our study, extensive
28 (56%) patients required inotropes, 10 study of SOFA score was done from day 1
(20%) patients required dialysis again to the last day. The SOFA score on day 1
supporting significant organ dysfunction. was high among non survivors and low
The mortality recorded in this study is 36%. among survivors which was statistically
In large clinical trials, the mortality significant (10.17 v/s 7.94, p=0.014).
associated with severe sepsis and septic However, the most significant difference
shock ranges between 13% and 50%.7 was observed on day 3. The SOFA score
was very high among non-survivors as
The non-survivors had a higher pulse rate compared to survivors which was
(mean 123.44 v/s 117.63 p=0.033) and a statistically very significant (13.42 v/s 6.84,
lower blood pressure and therefore a greater p<0.001). This was similar to many studies
requirement for inotropes (72.2% vs 46.9%, that have been done. Vosylius et al in their
p=0.08). compared to survivors .In our study on 117 ICU patients with sepsis
study, mortality rate among septic shock showed that the changes in the severity of
patients was 72.2%. Septic shock was organ dysfunction were closely related to
associated with a higher mortality as shown the outcome of the patients admitted to ICU.
with studies in Europe, by Jacobson et al8 & The SOFA score on day 3 was better
72.1% in Croatia by Degoricija et al9 compared with SOFA score on day 1 as the
.However, an Indian study by Todi et al had tool for outcome prediction 10
recorded a mortality of 59.26% in patients Vincent et al in their study in 40 ICUs in 16
with severe sepsis and septic shock 4 . countries showed that the total SOFA score
Although the observed high respiratory rate increased in 44% of the non-survivors but in
in non survivors than survivors (27.22 v/s only 20% of the survivors 12. Saulius
26.5) was not statistically significant Vosylius 10 in Vilnius, Lithuania observed
(p=0.658), but there was significantly more that SOFA score on day 1 and day 3 was
need of mechanical ventilation in non- significantly higher in non-survivors than
survived patients (88.9% vs 43.8%, p= those in survivors.
0.002). . Among the haematological
Among other clinical parameters, mean parameters, leukocytosis and leukopenia are
GCS among survivors was high compared often associated with mortality and normal
to non survivors on all days (day1, 14.19 v/s white blood cell counts are associated with
10.19 ) and was statistically very significant survival 8,13. In our study however non-
(p<0.001) which is in accordance with the survivors had a mean total count of 15,827/
finding by Vosylius et al10 and Bastos et al L and survivors had a mean total count of
11
that admission GCS was an independent 22, 893 /L at admission which was was not

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statistically significant though. Biochemical bacteria while 47% were Gram-positive
parameters were not statistically different bacteria and 19% were fungi.16
among survivors & non-survivors.
The mean duration of ICU stay did not vary Blood culture was positive in only 18% of
between non survivors and survivors (3.72 cases of sepsis. Pseudomonas was the most
v/s 3.75). It may be attributable to early common organism isolated from blood
death among non-survivors and early culture 33.3 % followesd by Klebsiella 22.2
recovery among survivors. %. Angus DC et al (2001) in an analysis of
Definite microbiological evidence previous studies concluded that blood
of infection from culture of appropriate culture yielded microorganisms in only 20-
specimen and blood culture was found in 40% of cases of sepsis17 . Choudhury et al 18
56% of patients with sepsis .Culture of from Tirupathi reported that the ratio of
appropriate specimen( as determined from Gram positive to Gram negative bacteremia
history and clinical examination ), eg was 1:1 on blood culture analysis with Staph
sputum, urine, stool, pus, asctic or pleural aureas and Pseudomonas aeruginosa taken
fluid etc could identify a definite together comprisd 36.8% of the isolates.
microorganism in 38% of cases of sepsis. Sharma M et al 19 (2002) from Rohtak in
Overall, Gram negative bacteria were found 2002 reported blood culture positivity in
to be the predominant pathogens associated sepsis to be 33.9%. Gram negative
with sepsis. Most common organism organisms (88.8%) like Klebsiella,
responsible for sepsis overall, was Pseudomonas, E. Coli were the most
Klebsiella (36.8%), followed by common organisms isolated, followed by
Pseudomonas (26.3%). Vincent JL et al Staphylococcus aureas among the Gram
(2006) in a observational study in 198 positives.19 . Tanriover MD et al20 (2006)in
intensive care units in 24 European an observational study in a tertiary hospital
countries found definite microbiological in Turkey showed that the yield of blood
evidence of infection in 60% patients 14. cultures was 47.7% and Gram-negative
Engel C et al15in a German multicentre bacilli constituted the majority of pathogens
study in ICUs of university hospitals found (65.9%) isolated from bacteraemic patients
documented infection in 70% patients with in the hospital setting. Klebsiella spp.
sepsis. They also found Gramnegative (43.8%) was found to be the most common
bacilli to be the predominant organisms pathogen in Gram-negative bacteraemic
isolated from cultures in patients with sepsis episodes followed by E. Coli (37.5%). 20
(52.8%) 15 . Todi S et al (2010) in a
Blanco J et al21 (2008) in a prospective,
multicentric, prospective trial from 2006 to
observational multicentre study in Spain in
2009 in Indian ITUs found culture positivity
2002 found that microbiological
in 61.6% patients with sepsis. Gram-
documentation of infection from culture
negative organisms were responsible for
studies could be made in 64.5% of cases of
72.45% of cases and Gram-positive for
sepsis. Blood culture was positive in 31.7%
13.13% 4. Vincent JL et al (2009) reported
cases. Gram negative bacilli were the
in a study involving 14,000 ICU patients in
predominant organisms responsible (50%) .
75 countries, that microbiological culture
E. Coli was the major pathogen isolated,
were positive in 70% of the infected
followed by Staph. aureas, Pseudomonas
patients; 62% isolates were Gram-negative
and Klebsiella21. Chatterjee et al 22 (2009) in
another multicentric study in Indian ITUs

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