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Can SIRS occur without Sepsis from Infection?

Can SIRS occur without Sepsis from Infection?


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I am thinking this figure

It suggests me that there has to be Sepsis that infection can lead to SIRS.

I am thinking particularly the pathogenesis of Cryptococcus neoformans where

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    • asymptomatic and nonspecific pulmonary signs in normal patients
    • progressive systemic disease in immunocompromised patients

and the last row.

Can SIRS occur without preceding or simultaneous Sepsis?


According to the classification of sepsis, it is SIRS with a suspected or known source of infection. By definition therefore, sepsis without SIRS is not sepsis but SIRS can exist without sepsis. In all fairness though, SIRS can exist if you run for a while (elevated heart rate and respiratory rate by themselves qualify for a diagnosis of SIRS).

Sepsis is however not the same as a bacteraemia which may be caused even by brushing your teeth (although the bacteraemia in this case is transient).


Systemic Inflammatory Response Syndrome (SIRS)

In 1992, the American College of Chest Physicians (ACCP) / Society of Critical Care Medicine (SCCM) introduced definitions for systemic inflammatory response syndrome (SIRS) as well as sepsis, severe sepsis, septic shock and MODS (multiple organ dysfunction syndrome) (Table 1). The introduction of SIRS was intended to define a clinical response to a non-specific insult, either infectious or non-infectious in origin (Table 2). SIRS is defined as 2 or more of the following:

2. Heart rate >90 beats per minute

3. Respiratory rate >20 breaths per minute or PaCO2 <32 mm Hg

4. Abnormal white blood cell count (>12,000/mm3 or <4,000/ mm3 or >10% bands)

SIRS can be incited by ischemia, inflammation, trauma, infection or a combination of several &ldquoinsults&rdquo. SIRS is not always associated with infection. While not universally accepted, some have proposed the terms &ldquosevere SIRS&rdquo and &ldquoSIRS shock&rdquo to describe serious clinical syndromes that are not infectious in nature and thus cannot be labeled according to the various sepsis definitions (Table 1). These terms suggest organ dysfunction or refractor hypotension not related to an infectious etiology, but rather an ischemic, traumatic or inflammatory process. The goal of this monograph is to review SIRS. Sepsis will be covered elsewhere.


Post-Sepsis Syndrome

Post-sepsis syndrome (PSS) is a condition that affects up to 50% of sepsis survivors. It includes physical and/or psychological long-term effects, such as:

  • Difficulty sleeping, either difficulty getting to sleep or staying asleep
  • Fatigue, lethargy
  • Shortness of breath, difficulty breathing
  • Disabling muscle or joint pain
  • Swelling in the limbs
  • Repeat infections, particularly in the first few weeks and months following the initial bout of sepsis
  • Poor appetite
  • Reduced organ function, eg kidney, liver, heart
  • Hair loss
  • Skin rash

Psychological or emotional –

  • Hallucinations
  • Panic attacks
  • Flashbacks
  • Nightmares
  • Decreased cognitive (mental) functioning
  • Loss of self-esteem
  • Depression
  • Mood swings
  • Difficulty concentrating
  • Memory loss
  • Post-traumatic stress disorder (PTSD)

The risk of having PSS is higher among people admitted to an intensive care unit (ICU) and for those who have been in the hospital for extended periods of time. PSS can affect people of any age, but a study from the University of Michigan Health System, published in 2010 the medical journal JAMA, found that older severe sepsis survivors were at higher risk for long-term cognitive impairment and physical problems than others their age who were treated for other illnesses. Their problems ranged from no longer being able to walk to not being able to participate in everyday activities, such as bathing, toileting, or preparing meals. Changes in mental status can range from no longer being able to perform complicated tasks to not being able to remember everyday things.

The authors wrote, “…60 percent of hospitalizations for severe sepsis were associated with worsened cognitive and physical function among surviving older adults. The odds of acquiring moderate to severe cognitive impairment were 3.3 times higher following an episode of sepsis than for other hospitalizations.”

In addition, one in six survivors find they have difficulty remembering things, concentrating, and making decisions.

Children can also live with lasting issues related to sepsis. About 34% of pediatric sepsis survivors are not back to pre-sepsis functioning for at least 28 days after their hospitalization. The numbers could actually be higher as another study that included teachers who evaluated students who had had sepsis. The researchers found that 44% of the children who had been in septic shock had cognitive difficulties compared with healthy children. They are also more likely to have PTSD if they were treated in a pediatric ICU.

What causes post-sepsis syndrome?

For some patients, the cause of their PSS is obvious. Blood clots and poor blood circulation while they were ill may have caused gangrene, resulting in amputations of fingers, toes, or limbs. Damage to the lungs can affect breathing. Another study, published in 2012 in the journal Shock, researchers found that sepsis survivors may be more vulnerable to developing viral respiratory (lung) infections.

Other organs may be damaged as well, such as the kidneys or liver.

These lasting physical issues can be explained, but there is more to PSS that cannot yet be explained, such as the disabling fatigue and chronic pain that many survivors experience. Others complain of seemingly unrelated problems, like hair loss that may occur weeks after their discharge from the hospital.

Post-traumatic stress disorder

Many sepsis survivors also report symptoms of post-traumatic stress disorder (PTSD). Researchers have already recognized that ICU stays can trigger PTSD, which can last for years.

According to a 2013 Johns Hopkins study that looked at PTSD after ICU stays, people with a history of depression were twice as likely to develop PTSD after being in an ICU. The researchers also found that patients who had sepsis were more likely to develop PTSD.

It is important to note that PSS does not happen only in older patients or in those who were already ill. An editorial published in JAMA in October 2010, addressed PSS. In “The Lingering Consequences of Sepsis,” the author wrote, “The new deficits were relatively more severe among patients who were in better health beforehand, possibly because there was less room for further deterioration among patients who already had poor physical or cognitive function prior to the sepsis episode.”

In other words, healthy people may be expected to rebound quickly from such a serious illness, but they may actually have the opposite experience.

What can be done about post-sepsis syndrome?

Doctors and other healthcare professionals must recognize post-sepsis syndrome among sepsis survivors. This way, patients can be directed to the proper resources. Resources may include referrals for:

  • Emotional and psychological support (counseling, cognitive behavioral therapy, or neuropsychiatric assessment)
  • Physical support such as physical therapy or neurorehabilitation.

No matter how ill someone is after having sepsis, survivor Julie Osenton describes how most survivors feel: “You never feel safe. Every time some little thing happens you think, “Do I need to go to the hospital or is this nothing?

What is post-ICU syndrome and is it the same thing as PSS?

Post-ICU syndrome (PICS) is a recognized problem that can affect patients who have spent time in an intensive care unit, ICU. It is more likely among patients who have been sedated or placed on a ventilator. It is not unusual for someone in an ICU to become delirious – sometimes called ICU delirium. The longer a patient is in such a unit, the higher the risk of developing delirium or PICS. A study published in the New England Journal of Medicine found that some of these patients continued to have cognitive (mental) problems a year after discharge.

The difference between PICS and PSS may seem slight. PICS is ICU related. Patients who are admitted to the ICU are at risk for PICS. PSS, on the other hand, can occur in sepsis patients who were not treated in an ICU, but who had extended hospital stays. The risk increases according to the severity of the illness and how long the hospitalization. Patients with PSS may also have physical issues that aren’t usually related to PICS, such as amputations.

Are post-COVID syndrome and PSS the same thing?

There have been many articles in the press and online about COVID-19 long-haulers, so named because they experience lasting symptoms long after after they recovered from the coronavirus infection.

People who have severe COVID-19 have viral sepsis. COVID-19, the infection caused by the SARS-CoV-2 virus, causes sepsis and results in severe illness. Therefore, the symptoms associated with post-COVID syndrome are identical to PSS, except for the loss of taste and smell. However, since sepsis is rarely mentioned in relation to COVID-19, people have started to call the lasting issues post-COVID syndrome instead of PSS.

PSS letters for healthcare professionals and others.

Some people who believe they have signs of PSS might find it difficult to speak to healthcare professionals about their problems. This letter, addressed to people who work in the healthcare field, helps explain some of the issues involved in PSS. If you feel this letter would be helpful, please feel free to print it out and bring it to your doctor’s appointments.

To help explain post-sepsis issues to others, Sepsis Alliance has letters that explain sepsis and PSS to:

Carol Mulkern

I had been feeling a bit “run down” as my Mom had just died. Two weeks later I went to an urgent care facility as I had pain when I urinated. I was prescribed antibiotics but they didn’t seem to work after 7 days. I reluctantly agreed to go to the local ED as my daughter thought I seemed “off”. The previous evening I had had the cold sweats as I was literally shivering out loud. (Sepsis and Urinary Tract Infections) Upon my arrival to the ED, vitals, medical history, urine spec, and chest X-ray were done. While waiting for …

Stephanie S.

I was admitted into the hospital in August of 2020 because I couldn’t breathe. My lungs were shutting down and I went into respiratory failure. It turns out that the cause of all of it was an abscess near my tail bone that had turned into gangrene and sepsis. (Sepsis and Bacterial Infections) I was in a coma for seven days, intimated, and had to have three surgeries to remove the infection. Now, almost nine months later, my wound is still healing and I suffer from PTSD, anxiety, insomnia, nightmares, and memory loss. (Sepsis and Post-Traumatic Stress Disorder) As well …

Anne Packard

I never knew what sepsis was before this experience. In March 2020 when the Covid19 pandemic had just begun here in the United States, I was treated at home for other reasons, with an IV infusion, After the treatment I began to shiver and shake. My temperature rose to over 100 degrees. We thought it was due to a bacterial infection that entered my blood through the IV drip. (Sepsis and Invasive Devices) I called my doctor who advised me to stay put and he would come to me, as going to a hospital at that time posed a high …

Roberta Beddows

Year 2016 my friends dog was choking on a bone. A very small dog, I picked her up and put my fingers in to get it out. On the way out I got a tiny cut and it bled. (Sepsis and Animal Bites) When I got home I disinfected my finger. Never thinking much about it, approximately 3 days later, I was in a terrible state: temperature, delirious, vomiting, diarrhea, pain. I dragged myself to the hospital. Told them how I felt. Also about the little cut. They examined me and then sent me home. I could hardly stand. Taxi …

Steven Wirtz

My story about sepsis changed my life tremendously both financially and mentally. That day I was diagnosed with double phenomena and I went home and went to bed to sleep. (Sepsis and Pneumonia). During that same night, I woke up and went to seek help. While I was driving back home I was pulled over by a police officer for careless driving. As I was being interviewed and questioned, I was asked by the officer to perform a breathalyzer and not knowing at the time of sepsis, I had I couldn’t perform the breathalyzer and was arrested for failure and …


Pathogenesis

ARDS is a heterogeneous syndrome characterized by increased permeability of pulmonary capillary endothelial cells and alveolar epithelial cells. The cause of injury may be either direct (e.g., pneumonia and gastric aspiration) or indirect to the lung (e.g., non-pulmonary sepsis and trauma), although distinguishing direct from indirect injury may be difficult in some cases (e.g., pneumonia sepsis). Preclinical models have suggested that direct lung injury begins with an insult to the lung epithelium, but indirect lung injury originates with systemic endothelial damage due to inflammatory mediators5. Several studies have demonstrated differences of these two phenotypes in humans using a panel of plasma biomarkers. For instance, the levels of surfactant protein, which is a matrix of amphipathic lipoproteins and phospholipids used to prevent alveolar collapse, were significantly higher in direct ARDS patients6. On the other hand, the levels of angiopoietin and Von Willebrand factor, which are both dysregulated in endothelial injury, were significantly increased in indirect ARDS by trauma and non-pulmonary sepsis6,7,8. A biomarker panel which includes biomarkers of lung epithelial and vascular endothelial injury may be useful in understanding the pathogenesis of sepsis-induced ARDS, and for selecting patients in trials of new therapies targeted to the lung epithelium and vascular endothelium.


Sepsis: pathophysiology and clinical management

Sepsis, severe sepsis, and septic shock represent increasingly severe systemic inflammatory responses to infection. Sepsis is common in the aging population, and it disproportionately affects patients with cancer and underlying immunosuppression. In its most severe form, sepsis causes multiple organ dysfunction that can produce a state of chronic critical illness characterized by severe immune dysfunction and catabolism. Much has been learnt about the pathogenesis of sepsis at the molecular, cell, and intact organ level. Despite uncertainties in hemodynamic management and several treatments that have failed in clinical trials, investigational therapies increasingly target sepsis induced organ and immune dysfunction. Outcomes in sepsis have greatly improved overall, probably because of an enhanced focus on early diagnosis and fluid resuscitation, the rapid delivery of effective antibiotics, and other improvements in supportive care for critically ill patients. These improvements include lung protective ventilation, more judicious use of blood products, and strategies to reduce nosocomial infections.


Epidemiology

Incidence and prevalence

Despite its high associated mortality, comprehensive epidemiological data on the global burden of sepsis are lacking. A tentative extrapolation of data from high-income countries suggests that 31.5 million cases of sepsis and 19.4 million cases of severe sepsis occur globally each year, with potentially 5.3 million deaths annually 16 . These numbers are simply estimates because knowledge about the incidence and mortality of sepsis in low-income and middle-income countries remains scarce owing to scant data and the difficulty of generating population-level estimates in these regions 16� . Sepsis is also not tracked in the Global Burden of Disease report published by the WHO and World Bank, which monitor incidence, mortality and risk factors of the most important diseases in the world 19 . Given the high prevalence of infectious diseases associated with an increased risk of sepsis and septicaemia, such as HIV 20 , non-typhoid salmonella and Streptococcus pneumoniae 21 , a substantial burden of sepsis should be expected in regions affected by these diseases. Indeed, in 2013, lower respiratory tract infections ranked second among the leading causes of disability-adjusted life-years and accounted for Ϣ.5 million deaths globally, of which a considerable proportion could be considered sepsis 22 . Similarly, malaria and viral infections such as dengue are also major sources of systemic infections in low-income and middle-income countries, with the majority of overall deaths attributable to sepsis 23 .

Contemporary epidemiological studies from high-income countries suggest high incidence rates of hospital-treated sepsis, ranging from 194 per 100,000 inhabitants in Australia in 2003 (REF. 24 ) to 580 per 100,000 inhabitants in the United States in 2006 (REF. 25 ). In Germany, the incidence of hospital-treated sepsis cases between 2007 and 2013 increased from 256 to 335 cases per 100,000 inhabitants the proportion of patients with severe sepsis increased from 27% to 41% 26 .

Furthermore, for high-income countries, several prospective and retrospective epidemiological studies have presented data on the incidence, point prevalence, period prevalence and mortality of sepsis. These reports have extrapolated their results to a population level several have suggested dramatic increases in the occurrence of sepsis 27,28 . However, interpretation of these findings is hampered by the fact that many of the studies use various different methods and sepsis definitions, including the 1991 consensus criteria (BOX 1) or derivative WHO International Classification of Diseases (ICD) code abstractions for register studies. Indeed, many databases included the 1991 consensus criteria such that infection (typically characterized by fever and its accompanying tachycardia and an altered white blood cell count) and sepsis were often confounded. Accordingly, depending on the codes used to identify clinical sepsis, prevalence can differ substantially 29,30 . For example, one study compared four different methods of assessing sepsis using the same databases and showed that the incidence of sepsis varied more than threefold between methods 31 . Furthermore, the increased incidence of sepsis in some health care systems might be attributable to increased clinical awareness of sepsis and/or financial incentives for enhanced reimbursement for services by coding patients with sepsis. Thus, these variable definitions could explain the dramatic increase in the number of sepsis cases associated with a reduction in mortality rates in high-income countries.

Chart-based clinical validation of cases of sepsis identified through administrative databases has often revealed several fold higher incidence rates than observed in prospective or retrospective trials 27 . By contrast, other studies have suggested that, in administrative data from hospitals, septicaemia, sepsis and severe sepsis might not be coded correctly or missed 32,33 . Accordingly, there is an ongoing controversy on the accuracy of coding itself, especially when sepsis is less severe 33,34 . Furthermore, only hospitalized patients are included in these observational studies, whereas a considerable number of patients experience sepsis outside the hospital setting 35 . As such, concerns abound that recent epidemiological data from high-income countries are unable to capture the real burden of sepsis, but there is little controversy that sepsis remains a considerable challenge in the developed world.

Mortality

Estimates of sepsis associated with in-hospital mortality are equally confounded. Between 1999 and 2009, mortality directly ascribed to sepsis seems to have declined on the basis of data obtained from death certificates or administrative databases. However, in many cases, especially in patients with chronic diseases such as cancer, congestive heart failure and chronic obstructive pulmonary disease, the official record of death often reports the underlying disease rather than the immediate cause of death (sepsis), which might contribute to the apparent underestimation in mortality from sepsis 35 . Data from Australia and New Zealand, in particular, have suggested that overall mortality rates attributable to sepsis are declining 13 . Although the percentages of patients with sepsis who are dying in the hospital are decreasing, Martin et al. 28 and Gaieski et al. 31 demonstrated that overall mortality rates tend to be increasing, due to the apparent increases in the number of patients with sepsis.

Whether mortality from septic shock is declining is less clear. Kaukonen et al. 13 reported from their administrative databases that mortality from septic shock has declined at rates comparable to those of sepsis. However, a cursory analysis of data from randomized controlled trials has suggested that, if mortality from septic shock is declining, it is doing so at a slower rate than for sepsis. The problem, in part, is that mortality rates from septic shock vary dramatically depending on the expertise and experience of the treating centre. In some countries, mortality from septic shock still approaches 50%, whereas in others, mortality is being reported at 20�% 36 .

The overall decreases in in-hospital sepsis mortality, and possibly in septic shock, are encouraging. However, given that the overall incidence of sepsis is seemingly increasing at greater rates, overall mortality is not significantly improving, demonstrating the continuing magnitude of the challenge.


Nosocomial Infections in the Pediatric Intensive Care Unit: Epidemiology and Control

Jacques Lacroix , . Anne G. Matlow , in Pediatric Critical Care (Third Edition) , 2006

Morbidity and Mortality

Systemic inflammatory response syndrome and multiple organ dysfunction syndrome are risk factors of nosocomial infection. Vice versa, nosocomial infections can cause or worsen these syndromes. 66 Bloodstream and respiratory nosocomial infections are deadlier than nosocomial skin, urinary tract, and eye infections in critically ill patients. However, underlying disease is the strongest predictor of death from a nosocomial infection. 31

Economic costs attributable to nosocomial infections are huge. In the United States, it was estimated that the economic burden associated with hospital-wide nosocomial infections in 1989 was $4 billion annually. 185


Pneumonia

Sepsis and septic shock can result from an infection anywhere in the body, including pneumonia. Pneumonia can be community-acquired, meaning that a person becomes ill with pneumonia outside of the hospital. Pneumonia can also be caused by a healthcare-associated infection (HAI), which affect 1.7 million hospitalizations in the United States every year. An HAI is an infection that is contracted by people while the hospital for a different reason, such as surgery or treatment for another illness.

Sometimes incorrectly called blood poisoning, sepsis is the body’s often deadly response to infection. Sepsis kills and disables millions and requires early suspicion and rapid treatment for survival.

Sepsis and septic shock can result from an infection anywhere in the body, such as influenza or urinary tract infections. Worldwide, one-third of people who develop sepsis die. Many who do survive are left with life-changing effects, such as post-traumatic stress disorder (PTSD), chronic pain and fatigue, organ dysfunction (organs don’t work properly), and/or amputations.

The most common source of infection among adults is the lungs.

What is pneumonia?

Pneumonia is an infection in the lungs. The infection can be only in one lung, or it can be in both. There are several causes of pneumonia but the most common are:

Left untreated, the infection can be deadly. In the days before antibiotics, it’s estimated that about one-third of those who developed bacterial pneumonia died.

Symptoms

Some people can have pneumonia and not know it, but the most common signs and symptoms are:

  • Fever
  • Cough, with phlegm
  • Shortness of breath
  • Sweating
  • Shaking chills
  • Headache
  • Muscle pain
  • Fatigue
  • Chest pain with breathing

You do not have to have all these symptoms to have pneumonia.

Who is at higher risk for developing the infection?

While anyone can develop pneumonia, some people are at higher risk than others. These include:

  • The elderly
  • The very young
  • People who recently had a cold or influenza
  • Smokers
  • Having a respiratory illness, such as chronic obstructive pulmonary disease (COPD)
  • Exposure to certain inhaled toxins
  • Having recently had surgery
  • People in intensive care units

What is the treatment?

Treatment depends on the type of infection you have.

Bacterial

Bacterial pneumonia is treated with antibiotics. The type of antibiotics your doctor may choose depends on the bacteria causing the infection. If you are given a prescription for antibiotics, it is essential that you finish all the medication, even if you start to feel better. You will begin to feel more like yourself before the infection is completely gone and if you stop taking the medications before the infection disappears, you could get a more serious pneumonia that can’t be treated as easily.

Viral

Viral pneumonia can’t be treated with antibiotics they will not do any good. In general, there isn’t much that can be done for viral pneumonia other than advising that you rest and take in plenty of fluids to stay hydrated. In some cases, doctors may prescribe an anti-viral medication, but this is not common.

Fungal

Fungal pneumonia is treated with medications called anti-fungals.

Preventing pneumonia

Pneumonia may be prevented in some cases. If you have surgery that requires general anesthetic, you could be at risk for developing bacterial infection. To lower the risk, you will likely be encouraged to get up and out of bed very quickly after the surgery. If it isn’t possible to get up and move around, you will be encouraged to breathe deeply and cough on a regular basis. This is to help keep your lungs clear.

There is a vaccine that can help prevent a common type of pneumonia called pneumococcal pneumonia. It is caused by a bacterium called Streptococcus pneumoniae. There is also a vaccine that doctors can give children to decrease the risk of developing one of four types of infections:

  • Meningitis (infection in the brain)
  • Bacteremia (infection in the blood)
  • Otitis media (infection in the middle ear)
  • Pneumonia

The vaccine is often recommended for the elderly and for people who are at high risk of developing pneumonia. If you fall into one of those categories, you may want to discuss this with your doctor.

If you suspect sepsis, call 9-1-1 or go to a hospital and tell your medical professional, “I AM CONCERNED ABOUT SEPSIS.”

The information here is also available as a Sepsis Information Guide, which is a downloadable format for easier printing.

Would you like to share your story about sepsis or read about others who have had sepsis? Please visit Faces of Sepsis, where you will find hundreds of stories from survivors and tributes to those who died from sepsis.


Criteria for Sepsis: Systemic Inflammatory Response Syndrome (SIRS) and Quick Sepsis-Related Organ Dysfunction Assessment (QSOFA)

Various definitions and scoring systems for sepsis were available but none of them was perfect due to the incomplete knowledge of sepsis syndrome pathobiology. Sepsis is a collection of diseases described mainly by systemic host response to infection. An international consensus first defined sepsis in 1991 and was later updated in 2001. Definitions of sepsis, severe sepsis, and septic shock remained the same for two decades. The systemic inflammatory response syndrome (SIRS) criteria were used widely in hospitals to identify sepsis. The third international consensus definitions for sepsis and septic shock (sepsis-3) recently revisited the definition. Sepsis and septic shock definitions were revised, while severe sepsis was omitted and considered to be redundant.

Recent Findings

The development in understanding sepsis pathobiology led to this new definition by a task force of sepsis clinicians and researchers. The sepsis-related organ failure assessment (SOFA) was developed to recognize sepsis, which replaced the SIRS criteria. Quick SOFA (qSOFA) was developed for patients outside intensive care units (ICUs) as a risk stratification tool to determine patients with suspected infection and poor outcomes in a quicker manner.

Summary

The third international sepsis consensus definitions task force aims to differentiate sepsis from uncomplicated infection and to update definitions of sepsis and septic shock as knowledge of sepsis syndrome pathobiology continues to improve.


GeriPal

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. On average, they had 1.5 new functional limitations, compared to their pre-sepsis baseline. These were major limitations that would have a profound effect on the ability to live independently. Examples of problems included requiring the help of a caregiver to manage finances, take medicine, bathe, or get dressed. In addition, there was a spike in cognitive impairment among survivors with a tripling of the risk for moderate or severe cogntive impairment.

Infection and sepsis are usually viewed as acute problems, with the assumption that the patient returns to normal if you "fix" the infection. But this study shows that among older persons, all is hardly normal once the infection is better. Many elders will go home to a different life. They will be less able to take care of themselves, and will be more reliant on family members and caregivers.

It would be interesting to note how often these new needs of sepsis survivors were recognized and anticipated by their hospital providers. But clinical experience suggests that most hospitals are structured in a way that made post-discharge care plans woefully inadequate. It is likely that infectious disease care was outstanding, but care directed at helping patients and their families manage new functional and cognitive impairment was poor.

These findings accentuate the need for better models of hospital and post-discharge care for elders admitted with serious illness. This care model needs to recognize that most of these elders will have a marked and often permament increase in disability. Our models of care need to help these elders live well with this disability and provide assistance to family members and other caregivers that help the elder stay at home.



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