CDC Epidemiologist Discusses Sepsis, COVID-19 Link

One of the constants in infection prevention and control involves trying to protect patients from sepsis. As a rule, infection preventionists are not generally that involved with fighting sepsis, but that might change says Runa Gokhale, MD, MPH, a medical epidemiologist with the Centers for Disease Control and Prevention (CDC). There’s no better time to get that message out than now, in September, which the CDC dubs Sepsis Awareness Month. In an interview with Infection Control Today^®, Gokhale says that “historically, we have not seen infection preventionists take on this role.” However, she adds that some recent projects undertaken by the CDC have “relied on infection preventionists to liaise with their colleagues to put in place protocols that will help to identify sepsis cases early on, whether in the emergency room or in the hospital.”

Infection Control Today^®: How can hospital systems be structured to best prevent sepsis?

Runa Gokhale, MD, MPH: I think it’s important for people to understand that sepsis is a medical emergency and is the body’s extreme response to infection. Almost any infection can lead to sepsis. And if left untreated or without timely treatment, sepsis can lead to tissue damage, organ failure, and even death. It’s important that health care systems are able to quickly identify and address sepsis across the spectrum of health care from outpatient care to inpatient acute care. And there are several things that health care systems can do to prevent sepsis and to reduce morbidity and mortality related to sepsis. Some of those things have been highlighted by our

Runa Gokhale, MD, MPH

ongoing COVID-19 pandemic. Severe COVID-19 can be considered as the body’s extreme response to COVID-19, which can be considered a form of sepsis that requires specific treatments as well as standard sepsis care. Some things that health care systems can do are to utilize technologies to implement screening programs to identify sepsis early include judicious use of antibiotics, targeted therapies that specifically treat infections that will prevent infections becoming sepsis, and can reduce morbidity and mortality related to sepsis, better diagnostics that can more accurately diagnose infections so that targeted therapies can be employed. And these are some of the strategies that we’ve seen in place for COVID-19. As well as the use of vaccinations when available. They can also implement layered prevention strategies, such as the use of face masks, hand hygiene, and other strategies that are simple, but helped to prevent the spread of infection and therefore can prevent sepsis. These are just some of the things that health care systems can implement to prevent sepsis and reduce mortality related to sepsis.

ICT^®: One of our Editorial Advisory Board members told me that infection preventionists don’t really play that much of a role in monitoring and preventing sepsis. Is that true? And if it’s true, should that change?

Gokhale: I think sepsis prevention is something that requires buy-in across the spectrum of personnel within the health care systems. And I think infection preventionists can be a big part of that. I mean, historically, we have not seen infection preventionists take on this role. But some of the projects that we’ve been engaged in through the CDC have relied on infection preventionists to liaise with their colleagues to put in place protocols that will help to identify sepsis cases early on, whether in the emergency room or in the hospital. And I think we’ve seen infection preventionists play a huge role in some of the COVID-19 mitigation strategies and health care systems such as making sure that PPE [personal protective equipment] preservation strategies are in place so that all health care personnel can have access to require PPE. Whether that’s talking about protocols for how patients are seen in the hospital to make sure that those with active symptoms of infection are kept away from patients without active symptoms of infection so that we can mitigate the spread of infection. And the judicious use of antibiotics. I think infection preventionists have played a large role in antimicrobial stewardship programs in hospitals and I think antimicrobial stewardship is an often an underappreciated aspect of sepsis prevention and sepsis management. The overuse of antibiotics can lead to more resistant infection, which then can lead to more sepsis. And so, I hear that statement, but I think that there is a role for infection preventionists to play here, and they are a community that we’ve been trying to engage through some of our sepsis awareness and sepsis prevention efforts.

ICT^®: You just mentioned CDC projects that try to improve sepsis prevention. Can you tell us more about those?

Gokhale: Sure. Some of them have been in place for some time, and some of them are newer, but are based on older work. One of the things that we’ve had in place for quite some time is our national education campaign Get Ahead of Sepsis. That launched in 2017 and has continued in various iterations to the present. We’re now incorporating some COVID-19 messages into our 2021 version of Get Ahead of Sepsis, and expanding our target audiences for that educational campaign, recognizing that there are many within the health care profession who aren’t necessarily familiar with sepsis as a term and with the signs and symptoms of sepsis. Some of our new target audiences are within the health care spectrum, including medical technicians, and sitters within the long-term care space, who really have lots of contact with residents and are well positioned to identify sepsis in its early stages, but might not be as familiar with what the signs and symptoms of sepsis are. Those are some of the projects that we’ve had long-standing that we’re continuing. Some of the newer projects we’ve engaged in…. There was a tool that was developed by two CDC colleagues, in collaboration with some of our academic research partners, that uses clinical data contained in electronic medical record systems to objectively define sepsis rather than relying on death record data or administrative coding. This has really helped us to look at sepsis through an objective lens in health care systems, and we have been working with some of our surveillance partners to implement this tool in health care systems to see if it is a feasible tool to use in health care systems. And we have had some communication with some health care systems who have implemented it who have found it very useful as a quality improvement and surveillance tool. It’s important to recognize that this may not be a tool that’s useful for screening. But for health care facilities who are attempting to track progress in their sepsis outcomes, this can be a useful tool. That is something that is a little bit newer. We have an epidemiology project that we undertook several years ago looking at risk factors associated with sepsis. And we have been sorting through and releasing the data related to that project as well.

ICT^®: Older people seem to be more vulnerable to sepsis. And COVID-19 in the beginning primarily attacked older people. How do you tie those threads together? What did you learn from COVID-19?

Gokhale: That’s a great point and it really underscores the issue that you can’t divorce infection from sepsis. As you mentioned, sepsis is really the body’s extreme response to infection. Those who are vulnerable to infection are also going to be vulnerable to sepsis. So that observation that sepsis seems to more heavily affect older populations—we do identify older populations, children younger than 1, and people with immunocompromised or chronic medical conditions as those who are at higher risk for sepsis. They are also populations who are at higher risk for infection. The two are necessarily married there.

ICT^®: As you know, COVID-19 moves so fast and it’s so new that some of the data we report has yet to be peer reviewed. Now, it seems as if the delta variant targets a younger demographic. In the initial data that you’ve seen, is sepsis a problem with COVID-19 and a younger demographic?

Gokhale: I think anytime we see severe outcomes of infection, we need to be concerned for sepsis because the severe COVID-19 is essentially one form of sepsis. I think that we need to be vigilant for signs of increasing frequency of severe disease associated with COVID-19. And I think that we need to make sure that providers within health care systems are aware to look out for the signs and symptoms of severe infection, particularly as we consider new variants and the impact that they might have on the clinical picture that we’re seeing among persons who are affected by those new variants, delta included.

ICT^®: If you were a hospital administrator what would you do to address the problem of sepsis given that hospital administrators have a lot of problems that need to be addressed?

Gokhale: That’s a great question. And you’re right, there are so many things that hospital administrators are faced with. I think one of the things that hospital administrators can do is make sure that their providers have access to the most up-to-date information regarding the current infections that are a threat to their community, and resources that are available to identify and address those infections. I think that includes COVID-19. But it also includes things like influenza and RSV [respiratory syncytial virus] for pediatric hospitals. And making sure that their providers have access to some of the resources that are available on the CDC website, as well as others, including some information that we have in the Get Ahead of Sepsis campaign about the signs and symptoms of sepsis so that their staff can be on high alert for signs of infection that might be progressing to sepsis. I think using all of their available resources, including infection preventionists, and others within the health care system to really amplify these messages. And make sure that that all staff are aware of the spectrum of disease that can be present in the face of infection. Some might be coming into the emergency room with mild infection and not necessarily needing admission, but being able to know what the signs and symptoms are, that might be a red flag that something more serious is going on, and that there may be a need for escalation of care. I think that those are some of the things that hospital administrators could focus on.

ICT^®: Before COVID-19 struck, what were the trends in sepsis? Was it going up? Down? Staying static?

Gokhale: That’s an interesting question, and one that is more complicated than it might seem. Prior to COVID-19, and through administrative data—so this is coding for sepsis—we were seeing sepsis incidents increase and mortality decrease. However, when we looked at that through a clinical lens using the toolkit that I mentioned earlier, it looks like sepsis incidence and mortality has stayed fairly steady over the last several years. It seems that likely what is happening is that we are capturing more sepsis through administrative coding, but we’re capturing more mild sepsis rather than severe sepsis. When we use the objective clinical definition, we’re really looking at more severe sepsis, and it seems that the incidence of more severe sepsis has stayed more or less stable over time. Now, that does not take into account COVID-19 data. I am not able to tell you what sepsis looks like since COVID-19 has been on the scene, but pre-COVID-19, that’s what we were seeing.

ICT^®: Doctor Gokhale, is there something that I neglected to ask you that you think is pertinent that you want your fellow health care professionals and infection preventionists to know about this?

Gokhale: I really appreciate you taking this topic on. I think Sepsis Awareness Month is the perfect month to talk about some of the things we are doing around sepsis and the importance of being vigilant for sepsis. And I think the only thing I would mention that we didn’t get to talk about is that there is a large community of individuals who have experienced sepsis or critical illness and who are dealing with the long-term effects of that infection or of that illness. And that’s another area where we are interested in collecting more information and there are some great physicians and researchers out there looking into this. I think that dovetails with what we’re seeing with the long-term consequences of COVID-19. And what some folks are experiencing with that. I want people to know that that is an area that we are aware of and that we’re working in. And also, just recognizing that this pandemic has really highlighted the needs and circumstances of special populations and health equity concerns. And that is something that had been recognized in sepsis work as well, but that we’ve really seen with COVID-19 and I think is another area that those disciplines or those themes can learn from each other. I just want to thank you for this opportunity to talk about COVID-19 and to just encourage our infection preventionists and health care partners to reach out for resources related to sepsis and to make sure that they are up to date on the most current and accurate information regarding sepsis and are vigilant for the signs and symptoms of sepsis.

This interview has been edited for clarity and length.