Summary
The early diagnosis of sepsis is mandatory for the further reduction of mortality due to sepsis. Current findings exist that accentuate the role of the time factor, comparable with acute myocardial infarction or with ischemic stroke. On the other hand, there are no generally accepted diagnostics for sepsis, realizing the demands of early diagnosis and based on the physician’s experience.
The diagnostics start with the recognition of the inflammatory reaction caused by infection (at least 2 of 4 criteria of inflammatory reaction have to be fulfilled). This definition has high sensitivity, but remarkably lower specificity and it leads either to too frequent admissions or only to hospitalization in case of a complicating organ failure. Making a careful history and knowledge about sepsis are essential for the out-patient department physicians. In addition to the varying pictures of sepsis, the clinicians have laboratory findings available, most of all procalcitonin. Patients have to be considered as septic with a serum PCT level higher than 1 ng/ml particularly when clinical signs do not exclude sepsis and in cases of positive blood cultures. Initially PCT is a product of macrophages if the defense reaction starts, but it becomes an infection marker, when the serum PCT level declines less than the half life falls.
Zusammenfassung
Die frühe Diagnostik der Sepsis ist das Nadelöhr für die weitere Senkung der Sepsissterblichkeit. Inzwischen liegen Befunde vor, dass, vergleichbar mit akutem Myokardinfarkt und Schlaganfall, dem Faktor Zeit eine wichtige Rolle zukommt. Demgegenüber gibt es keine allgemein akzeptierte Sepsisdiagnostik, die der Forderung nach früher Diagnose und der Unabhängigkeit vom Erfahrungsstand des jeweiligen Arztes Rechnung tragen könnte.
Ausgangspunkt der Diagnose ist die durch Infektion hervorgerufene inflammatorische Reaktion (mindestens 2 von 4 SIRS-Kriterien erfüllt), die eine hohe Sensitivität, aber eine geringe Spezifität besitzt. Hier besteht das Dilemma für die ambulant tätigen Ärzte, die dann entweder zu häufig einweisen oder erst einweisen, wenn die Sepsis zum Organversagen geführt hat. Der ambulante Arzt kommt um das sorgfältige Erheben der Anamnese und das Wissen der Befunde bei Sepsis nicht herum. Ärzten von Notaufnahmen und klinisch tätigen Ärzten steht neben dem Wissen um die variable Klinik des septischen Patienten vor allem der Laborparameter Procalcitonin zur Verfügung. Patienten mit einem PCT≥1 ng/ml sollten als septisch betrachtet werden, wenn die Klinik die Sepsis nicht ausschließt und erst recht dann, wenn positive Blutkulturbefunde vorliegen. PCT ist zunächst das Produkt der Makrophagen am Beginn der Abwehrreaktion, wird aber zum Infektionsmarker, wenn der Abfall des Serum-PCT nicht dessen Halbwertzeit folgt.
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Literatur
Dellinger RP, Carlet JM, Masur H et al (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32:858–873
Poeze M, Ramsay G, Gerlach H et al (2004) An international sepsis survey: a study of doctors’ knowledge and perception of sepsis. Crit Care 8:R409–R413
ACCP/SCCM Consensus Conference Committee (1992) Definition for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874
Brunkhorst FM, Engel C, Welte T et al (2005) Prevalence of infection in German intensive care units—results from the German Prevalence Study. Infection 33 (Suppl 1):47
Reinhart K, Brunkhorst FM, Bloos F et al (2006) S2 Leitlinien der Deutschen Sepsis-Gesellschaft e.V. und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin. AWMF-Leitlinien-Register Nr. 079/001
Levy MM, Fink MP, Marshall JC et al (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 31:1250–1256
Wheeler AP, Bernard GR (1999) Treating patients with severe sepsis. N Engl J Med 340:207–214
Seifert H, Abele-Horn M, Fätkenheuer G et al (2006) Sepsis-Blutkulturdiagnostik. In: Mauch H, Podbielski A, Herrmann M (Hrsg) Mikrobiologisch-infektiologische Qualitätsstandards. MiQ 3. Urban & Fischer, München, S1–S155
Mewald Y, Hamann GF (2005) Versagen des zentralen, peripheren und vegetativen Nervensystems. Intensivmed 42:250–263
Seifried E (1995) Disseminierte intravasale Gerinnung. Hämostaseologie 15:57–64
Taylor FB, Toh CH, Hoots WK et al (2001) Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Heamost 86:1327–1330
Wu AHB (2001) Increased troponin in patients with sepis and septic shock: myocardial necrosis or reversible myocardial depression? Intensive Care Med 27:959–961
Witthaut R, Busch C, Fraunberger P et al (2003) Plasma atrial natriuretic peptide and brain natriuretic peptide are increased in septic shock: impact of interleukin-6 and sepsis-associated left venticular dysfunction. Intensive Care Med 29:1696–1702
Carpentier J, Luyt CE, Fulla Y et al (2004) Brain natriuretic peptide: a marker of myocardial dysfunction and prognosis during severe sepsis. Crit Care Med 32:660–665
Latronico N, Fenzi F, Recupero D et al (1996) Critical illness myopathy and neuropathy. Lancet 347:1579–1582
Schmidt H, Müller-Werdan U, Hoffmann T et al (2005) Autonomic dysfunction predicts mortality in patients with multiple organ dysfunction syndrome of different age groups. Crit Care Med 33:1994–2002
Volk HD, Reinke P, Döcke WD (1999) Immunological monitoring of the inflammatory process: which variables? When to assess? Eur J Surg 584 (Suppl):70–72
Vincent JL, de Medoza A, Cantraine F et al (1998) Use of the SOFA score to assess the incidence of organ dysfunction/failure in tntensive care units: results of a multicenter, prospective study. Crit Care Med 26:1793–1800
Levy MM, Macias WL, Vincent JL et al (2005) Early changes in organ function predict eventual survival in severe sepsis. Crit Care Med 33:2194–220
Brun-Buisson C, Doyon F, Carlet J et al (1996) Bacteremia and severe sepsis in adults: a multicenter prospective survey in ICUsand wards of 24 hospitals. Am J Respir Crit Care Med 154:617–624
Danner RL, Elin RJ, Hosseini JM, Wesley RA et al (1991) Endotoxemia in human septic shock. Chest 99:169–175
Engelmann L, Al Zoebi A, Pilz U, Werner M et al (1996) Die Bedeutung der Endotoxinbestimmung bei Sepsis. Intensivmed 33:253–259
Assicot M, Gendrel D, Carsin H et al (1993) High serum procalcitonin concentrations in patients with sepsis and infection. Lancet 341:515–518
Müller B, Becker KL, Schächinger H et al (2000) Calcitonin precursors are reliable markers of sepsis in a medical intensive care unit. Crit Care Med 28:977–983
Steinbach G, Rau B, Debard AL et al (2004) Multicenter evaluation of a new immunoassay for procalcitonin measurement on the Kryptor® system. Clin Chem Lab Med 42:440–449
Clec’h C, Ferriere F, Karoubi P et al (2004) Diagnostic and prognostic value of procalcitonin in patients with septic shock. Crit Care Med 32:1166–1169
Christ-Crain M, Jaccard-Stolz D, Bingisser R et al (2004) Effect of procalcitonin-guided treatment an antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet 363:600–607
Cohen J, Brun-Buisson C, Torres A, Jorgenden J (2004) Diagnosis of infection in sepsis: an evidence-based review. Crit Care Med 32 (Suppl):S466–S494
Brunkhorst FM, Engel C, Stüber F et al (2005) Diagnoszic criteria for severe sepsis and septic shock: a representative survey among german ICU physicians-results from the German Prevalence Study. Infection 33 (Suppl. 1):47
Linscheid P, Seboek D, Schaer DJ et al (2004) Expression and secretion of procalcitonin and calcitonin gene-related peptide by adherent manocytes and by macrophage-activated adipocytes. Crit Care Med 32:1715–1721
Kruse, ER, Langefeld I, Jaeger K, Külpmann WR (2000) Procacitonin—a new diagnostic tool in complications following liver transplantation. Intensive Care Med 26:S187–S192
Rau B, Krüger CM, Schilling MK (2004) Procalcitonin: improved biochemical severity stratification and postoperative monitoring in severe abdominal inflammation and sepsis. Langenbecks Arch Surg 389:134–144
Lateef A, Khoo SM, Lee KH (2005) Procalcitonin in hypoxic brain damage. Intensive Care Med 31:494
Delevaux I, Andre M, Colombier M et al (2003) Can procalcitonin measurement help in differentiat ing between bacterial infection and other kinds of inflammatory processes? Ann Rheum Dis 62:337–340
Brunkhorst FM (1998) Kinetics of procalcitonin in iatrogenic sepsis. Intensive Care Med 24:88–889
Engelmann L, Petros S, Gundelach K, Wegscheider K (2006) Die Bedeutung des „second hit“ für den Sepsisverlauf. Intensivmed 43:189–201
Herbarth S, Holeckova K, Froidevaux et al (2001) Diagnostic value of procalcitonin, interleukin-6, and interleukin-8 in critically ill patients admitted with suspected sepsis. Am J Respir Crit Care Med 164:396–402
Whicher J, Bienvenu J, Monneret G (2001) Procalcitonin as an acute phase marker. Ann Clin Biochem 38:483–493
Kylänpää-Bäck ML, Takala A, Kemppainen E et al (2001) Procalcitonin, soluble interleukin-2 receptor, and soluble E-selectin inpredicting the severity of acute pancreatitis. Crit Care Med 29:63–69
Pettilä V, Hynninen M, Takkunen O, Kuusela P, Valtonen M (2002) Predictive value of procalcitonin and interleukin-6 in critically ill patients with suspected sepsis. Intensive Care Med 28:1220–1225
Simon L, Gauvin F, Amre DK et al (2004) Serum procalcitonin and C-reactive protein levels as marker of bacterial infections: a systematic review and meta-analysis. CID 39:206–217
Liaudat S, Dayer E, Praz G, Bille J, Troillet N (2001) Usefulness of procalcitonin serum levels for the diagnosis of bacteremia. Eur J Clin Microbiol Infect Dis 20:524–527
Manegold C, Schmiedel S, Chiwakata CB, Dietrich M (2003) Procalcitonin serum levels in tertian malaria. Malar J 2:34
Jereb M, Kotar T (2006) Usefulness of procalcitonin to differentiate typical from atypical community-aquired pneumonia. Wien Klin Wochenschr 118:170–174
Masid M, Gutierrez F, Shum C et al (2005) Usfulness of procalcitonin levels in community-aquired pneumonia according to the patients outcome research team pneumonia team severity index. Chest 128:2223–2229
Boussekey N, Leroy O, Alfandari S et al (2006) Procalcitonin kinetics in the prognosis of severe community-aquired pneumonia. Intensive Care Med 32:469–472
Giamarellou H, Giamerellos-Bourboulis EJ, Repoussis P et al (2004) Potential use of procalcitonin as a diagnostic criterion in febrile neutropenia: experience from a multicentre study. Clin Microbiol Infect 10:628–633
Whicher J (1998) C-reaktives Protein (CRP) In: Thomas L (Hrsg) Labor und Diagnose, 5. Aufl. TH-Books Verlagsgesellschaft mbH, Frankfurt/Main, S717–S724
Wahl HG, Herzum I, Renz H (2003) Spsis und Sepsismarker–Update. J Lab Med 27:431–439
Meisner M, Tschaikowsky K, Palmears T, Schidt J (1999) Comparison of procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations at different SOFA scores during the course of sepsis and MODS. Critical Care 3:45–50
Calandra T, Gerain J, Heumann D et al (1991) High circulating levels of interleukin-6 in patients with septic shock: evolution during sepsis, prognostic value, and interplay with other cytikines. Am J Med 91:23–29
Martin C, Saux P, Mege JL et al (1994) Prognostic value of serum cyteokines in septic shock. Intensive Care Med 20:272–277
Marty C, Misset B, Tamion F et al (1994) Circulating interleukin-8 concentrations in patients with multiple organ failure of septic and nonseptic origin. Crit Care Med 22:673–679
Parson PE, Moss M (1996) Early dedection and markers of sepsis. Clin Chest Med 17:199–212
Walley KR, Lukacs NW, Standiford TJ et al (1996) Balance of inflammatory cytokines related to severity and mortality of murine sepsis. Infect Immun 64:4733–4738
Dinarello CA (1997) Proinflammatory and anti-inflammatory cytokines as mediators in the pathogenesis of septic shock. Chest 112:321S–329S
Gogos CA, Drosou E, Bassaris HP, Skoutelis A (2000) Pro-versus anti-inflammatory cytokine profile in patients with severe sepsis: a marker for prognosis and future therapeutic options. JID 181:176–180
Brauner JS, Rohde LE, Clausell N (2000) Circulating endithelin-1 and tumor necrosis factor-α: early predictors of mortality in patients with septic shock. Intensive Care Med 26:305–313
Oberholzer A, Oberholzer C, Moldawer LL (2002) Interleukin-10: a complex role in the pathogenesis of sepsis syndroms and ist potential as an anti-inflammatory drug. Crit Care Med 30 (Suppl):S58–S63
Volk HD, Reinke P, Krausch D et al (1995) HLA-DR-Expression auf Monozyten bei Peritonitis und Sepsis—Möglichkeiten eines therapeutischen Ansatzes. Chir Gastroenterol 11 (Suppl 2):34–41
Döcke WD, Syrbe U, Meinecke A et al (1994) Verbesserung der Monozytenfunktion—ein therapeutischer Ansatz? In: Update in Intensive Care and Emergency Medicine Bd 18. Springer, S 473–488
Hörner C, Bouchon A, Bierhaus A et al (2004) Bedeutung der angeborenen Immunantwort in der Sepsis. Anästhesist 53:10–28
Perry SE, Mostafa SM, Wenstone R et al (2003) Is low monocyte HLA-DR expression helpful to predict outcome in severe sepsis? Intensive Care Med 29:1245–1252
Oczenski W, Krenn H, Jilch R et al (2003) HLA-DR as a marker for increased risk for systemic inflammation and septic complications after cardiac surgery. Intensive Care Med 29:1253–1257
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Serie: Die Intensivtherapie bei Sepsis und Multiorganversagen Herausgegeben von L. Engelmann (Leipzig)
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Engelmann, L. Die Diagnose der Sepsis. Intensivmed 43, 607–618 (2006). https://doi.org/10.1007/s00390-006-0741-y
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DOI: https://doi.org/10.1007/s00390-006-0741-y