Internal Medicine · Year 3 · from Internal Medicine
Case 1: Sepsis from Urinary Source
Patient Presentation
A 76-year-old woman with a history of type 2 diabetes and recurrent urinary tract infections presents with confusion, fever, and decreased oral intake for 2 days. Her daughter reports she has been more tired than usual and not acting like herself. She lives independently but needed help getting dressed today. She has an indwelling urinary catheter that was placed 3 weeks ago for urinary retention.
Vital Signs
- Blood Pressure: 88/52 mmHg
- Heart Rate: 108 bpm
- Respiratory Rate: 24/min
- Oxygen Saturation: 94% on room air
- Temperature: 39.2°C
Physical Examination
- General: Ill-appearing, confused, oriented to name only
- Cardiovascular: Tachycardic, regular rhythm, warm extremities
- Pulmonary: Clear
- Abdomen: Suprapubic tenderness, no rebound
- Skin: Warm, flushed
- Foley catheter: Cloudy urine with sediment
Laboratory Results
- WBC: 18,200/μL with 22% bands
- Creatinine: 2.4 mg/dL (baseline 1.0)
- Lactate: 4.2 mmol/L
- Urinalysis: Large leukocyte esterase, positive nitrites, >100 WBC/hpf, bacteria present
- Blood glucose: 320 mg/dL
Clinical Image
Figure 1: Diagram illustrating the pathophysiology of sepsis: infection triggers systemic inflammatory response leading to organ dysfunction through cytokine release, endothelial dysfunction, and microcirculatory failure.
Image Source: Educational illustration for teaching purposes.
Questions
- What is the Sepsis-3 definition of sepsis?
- A) SIRS criteria plus suspected infection
- B) Life-threatening organ dysfunction caused by dysregulated host response to infection
- C) Bacteremia with fever
- D) Any infection requiring hospitalization
- What is this patient's qSOFA score?
- A) 0
- B) 1
- C) 2
- D) 3
- Does this patient meet criteria for septic shock?
- A) No, blood pressure is not low enough
- B) Yes, she has sepsis with hypotension and lactate >2 despite fluid resuscitation
- C) Cannot determine without central line
- D) Shock only defined by need for vasopressors
- What are the components of the Hour-1 Bundle for sepsis?
- What is the appropriate empiric antibiotic choice for urosepsis?
Answers
- B) Life-threatening organ dysfunction caused by dysregulated host response to infection - Sepsis-3 (2016) defines sepsis as infection plus organ dysfunction, identified by increase in SOFA score ≥2 points. This replaced the older SIRS-based criteria.
- D) 3 - qSOFA (quick SOFA) criteria:
- Respiratory rate ≥22: Yes (24) = 1 point
- Altered mental status: Yes (confused) = 1 point
- Systolic BP ≤100: Yes (88) = 1 point
- Total = 3 points; score ≥2 suggests increased mortality risk
- B) Yes, she has sepsis with hypotension and lactate >2 despite fluid resuscitation - Septic shock = sepsis with:
- Persistent hypotension requiring vasopressors to maintain MAP ≥65, AND
- Lactate >2 mmol/L despite adequate fluid resuscitation
- This patient likely has septic shock given her presentation; formal diagnosis requires demonstrating fluid unresponsiveness.
- Hour-1 Bundle for sepsis:
- Measure lactate (remeasure if initial >2 mmol/L)
- Obtain blood cultures before antibiotics
- Administer broad-spectrum antibiotics
- Begin rapid fluid resuscitation (30 mL/kg crystalloid for hypotension or lactate ≥4)
- Apply vasopressors if hypotensive during or after fluid resuscitation (target MAP ≥65)
- Goal: Complete all elements within 1 hour of sepsis recognition
- Empiric antibiotics for urosepsis:
- Piperacillin-tazobactam, OR
- Ceftriaxone (if low ESBL risk), OR
- Cefepime, OR
- Carbapenem (if high ESBL/resistance risk)
- Consider adding vancomycin if enterococcal coverage needed
- Remove/replace the Foley catheter
- De-escalate based on culture and sensitivities