Sepsis itself has no special clinical manifestations, and the manifestations seen in sepsis can also be seen in other acute infections, such as most of them have a sudden onset, first chills or chills, followed by high fever, uncertain heat type, flaccid fever or missed fever; Weak, severely malnourished and small infants can have no fever, and even their body temperature is lower than normal. Mental depression or irritability, serious cases can appear pale or gray, delirious. Cold extremities, shortness of breath, accelerated heart rate, decreased blood pressure, and jaundice in infants and young children.
Various skin lesions can be seen in some children, including petechiae, ecchymosis, scarlet fever like rash and urticaria like rash. There were ecchymosis spots or ecchymosis spots of different sizes in meningococcal sepsis; Scarlet fever like rash is common in Streptococcus and Staphylococcus aureus sepsis. The gastrointestinal tract often has vomiting, diarrhea, abdominal pain, and even hematemesis and bloody stool; In severe cases, toxic intestinal paralysis, dehydration and acidosis may occur. It is more common in infants and young children, with mild or moderate swelling; Some children may be complicated with toxic hepatitis; Liver tenderness is obvious when liver abscess is caused by migratory damage of Staphylococcus aureus. Some children may have joint swelling and pain, movement disorder or joint cavity effusion, which is more common in large joints.
Severe children are often accompanied by symptoms of parenchymal organ involvement such as myocarditis, heart failure, blurred consciousness, drowsiness, coma, oliguria or anuria. Staphylococcus aureus sepsis often has multiple migratory lesions; Gram negative bacterial sepsis is often complicated with shock and DIC. Ecchymosis, ecchymosis, pus, cerebrospinal fluid, pleural effusion and ascites can also be directly smeared and examined under microscope to find bacteria.
Sepsis caused by different pathogens has different clinical characteristics.
1,Staphylococcus aureus septicemia is more common in nosocomial infection. When patients are treated with broad-spectrum antibiotics, this bacterium is easy to form drug-resistant strains (methicillin resistant strains). The number of this bacterium in respiratory tract and intestinal tract increases significantly, which can lead to systemic infection. It is also common after interventional treatment, such as artificial joint, artificial valve, pacemaker and various catheter indwelling.
2,The primary focus of Staphylococcus aureus sepsis is often skin furuncle, carbuncle or wound infection. A few are nosocomial infections with poor body resistance, and most of the bacteria in their blood come from the respiratory tract. The clinical onset is urgent. The rash is in many forms, such as ecchymosis, urticaria, purulent herpes and scarlet fever like rash. The occurrence of ecchymosis on the conjunctiva is of great significance. Joint symptoms are obvious, sometimes red and swollen, but suppuration is rare. The most common are multiple lung infiltration, abscess and pleurisy, followed by suppurative meningitis, renal abscess, liver abscess, endocarditis, osteomyelitis and subcutaneous abscess. Septic shock is rare.
3,Enterococcal septicemia enterococci are opportunistic bacteria, usually mainly parasitic in the intestinal and urinary system. Clinically, urinary tract infection and endocarditis are the most common. In addition, meningitis, osteomyelitis, pneumonia, enteritis and skin and soft tissue infection can also be seen. The incidence rate has increased in recent 30 years, accounting for about 10% of the nosocomial septicemia in China, and has risen to fourth in the United States.
4,Gram negative bacilli sepsis. ① Escherichia coli: it is the most common pathogen in Gram-negative bacilli septicemia. E. coli is one of the common bacteria in human intestine. It is generally not pathogenic, but it can cause serious infection when the normal barrier of human body is damaged and the resistance is reduced. ② Pseudomonas aeruginosa: it is a common pathogen of gram-negative bacilli septicemia in hospital. It mostly occurs in patients with systemic immunity decline or local injury, such as leukopenia caused by any reason, tumor patients undergoing chemotherapy and patients with large-area burns. The clinical manifestations are more dangerous, the rash can be and cardiac necrosis. ③ Klebsiella: pneumoniae is the most important. It often causes respiratory, urinary system infection and sepsis. Pneumonia bacilli sepsis often occurs in patients with immune dysfunction and the elderly. The main invasion routes are biliary tract and respiratory tract. ④ Enterobacter: aerogenic bacteria cause systemic infection. Sepsis caused by typhoid fever can also appear, accompanied by relative bradycardia. ⑤ Others: some usually non pathogenic gram-negative bacilli in the intestine, such as Alcaligenes, Acinetobacter, Serratia, etc., can also cause sepsis under certain circumstances. In severe cases, multiple organ function damage may occur, manifested as arrhythmia and heart failure
5,Anaerobic septicemia accounts for 5% ~ 10% of the pathogens of septicemia, including gram-negative fragile Bacteroides, gram-positive digestive cocci and Streptococcus. 80% ~ 90% of the pathogenic bacteria are fragile Bacteroides, in addition to anaerobic Streptococcus, digestive coccus and Clostridium perfringens. The main invasion routes were gastrointestinal tract and female reproductive tract, followed by bedsore and ulcer. The clinical manifestations are similar to those of aerobic septicemia. The characteristic manifestations are as follows: ① the incidence of jaundice is as high as 10% ~ 40%, which may be related to the hemolytic effect of Bacteroides endotoxin on the liver and a toxin of Clostridium perfringens; ② The secretion of local lesions has a special smell of corruption. ③ it is easy to cause septic thrombophlebitis and migratory lesions in thoracic cavity, lung, endocardium, abdominal cavity, liver, brain and bone joints, which are more common in fragile Bacteroides and anaerobic streptococcal sepsis. ④ Severe hemolytic anemia and renal failure can occur in Clostridium perfringens septicemia, and gas is formed in local migratory lesions. Anaerobic bacteria and aerobic bacteria often together cause plural bacterial sepsis, and the prognosis is dangerous.
6,The most common cases of fungal sepsis are Candida albicans, Mucor and Aspergillus. Most of the patients with fungal septicemia have severe underlying diseases, such as chronic liver disease, kidney disease, diabetes, hematological diseases or malignant tumors, or patients with severe burns, heart surgery and organ transplantation. Due to long-term or massive use of broad-spectrum antibiotics, corticiam or anti metabolic drugs, they cause normal bacterial flora imbalance or decreased resistance. The clinical manifestations of fungal sepsis are roughly the same as those of other sepsis, and most of them are accompanied by bacterial infection, so its toxemia symptoms are often covered up by simultaneous bacterial infection or primary symptoms, which is not easy to make a clear diagnosis in the early stage. Therefore, when the infection of the above patients still does not improve after the application of sufficient and appropriate antibiotics, the possibility of fungal infection must be considered. Fungal culture of blood, urine, pharyngeal swabs and sputum should be done. Sputum can also be directly smeared to check for fungal hyphae and spores. If the same fungal result is obtained in multiple or multiple samples, the pathogen can be determined. Lesions can involve heart, lung, liver, spleen, brain and other organs and tissues, form multiple small abscesses, and can also be complicated with endocarditis and meningitis.
Because the vast majority of sepsis is secondary to various infections and lack of specific clinical manifestations, it is easy to cause missed diagnosis or misdiagnosis. In order to improve the early diagnosis rate of sepsis, we must first improve our vigilance against sepsis and timely check the suspicious cases. Therefore, the possibility of sepsis should be highly suspected for those who have fever, elevated total leukocytes and neutrophils, recent respiratory tract, digestive tract and urinary tract infections or burns, history of instrument operation, and various focal infections that have not been effectively controlled after antibacterial treatment.
Positive blood culture bacteria is the most reliable diagnostic basis for sepsis. If blood culture is negative and bone marrow culture is positive, its significance is the same as that of blood culture. Other cultures such as sputum, urine, pleural effusion, ascites and purulent secretions are of reference significance for definite diagnosis. If the blood culture is negative and there are ecchymosis, rash, hepatosplenomegaly, migratory damage or abscess such as conjunctiva and oral mucosa during the course of the disease, the diagnosis of sepsis can also be basically established.