Septicopyemia is a form (phase) of the course of sepsis, which is characterized by the appearance of pyemic metastatic foci in various organs due to hematogenous infection. It proceeds with the phenomena of severe intoxication, aggravated by the formation of abscesses in soft tissues, liver, the development of abscessing pneumonia, purulent meningitis, osteomyelitis, endomyocarditis, etc. It is diagnosed according to the results of the clinical picture, instrumental visualization (detection of abscesses according to ultrasound, MRI), detection of bacteremia. The treatment combines massive antibiotic therapy, infusion therapy with surgical removal of purulent foci.
ICD 10
A41.9 A49.9
General information
Septicopyemia, or pyemia (from Greek. “septicopyaemia” – putrefactive-purulent blood infection) is purulent metastases to various tissues and organs in sepsis. It can be an independent clinical and anatomical form of the septic process (70%) or a stage following toxemia and septicemia (30%). It occurs in various age groups, including newborns. Despite the fact that the specific weight of septicopiemia in the structure of acute purulent surgical diseases is not so great (0.1%), the mortality rate, depending on the type of pathogen, reaches 30-80%.
Causes
The formation of secondary pyemic foci occurs with hematogenous dissemination of infection from the primary septic focus located in the skin and soft tissues, bones, lungs, abdominal cavity, kidneys, oropharynx, paranasal sinuses, vascular bed, etc.
When examining hemoculture, staphylococci (90%) are most often detected, usually its antibiotic-resistant strains. A significant role is played by Streptococci, Pseudomonas aeruginosa, proteus, E. coli, enterobacteria, anaerobes. Candida, Aspergillus, and actinomycetes predominate among the pathogens of mycotic sepsis. Polymicrobial infection is detected in almost half of cases. Mixed infection aggravates the course of sepsis and aggravates the prognosis.
Risk factors
The development of septicopyemia is facilitated by a decrease in immunoreactivity, which is most often observed in the following conditions:
- prematurity in children;
- immunodeficiency;
- diabetes mellitus;
- oncopathology;
- autoimmune diseases;
- chronic intoxication (alcohol, narcotic);
- condition after splenectomy.
At risk are women in labor, inpatient patients who have undergone surgery, receiving immunosuppressive therapy, undergoing hemodialysis, being on a ventilator, etc. In addition to increased susceptibility to various pathogenic agents, they are at risk of encountering nosocomial infection.
Pathogenesis
Among the mechanisms of sepsis, etiological agents, localization of infection gates and immunobiological reactivity of the body play the greatest role. More often, septicopyemia occurs independently, primarily, in about a third of cases – against the background of previous septicemia. Purulent lymphangitis, lymphadenitis, and thrombophlebitis develop at the gates of infection, acting as a source of thrombobacterial embolism.
The increasing systemic inflammatory reaction depletes the protective mechanisms: phagocytosis, complement system, antibody formation, etc. As a result, bacteremia becomes uncontrolled, the infection becomes generalized. Infected blood clots form in the vessels of the primary focus. With the blood flow, microbial emboli spread throughout the body, overcome histogematic barriers, penetrate into organs that are anatomically unrelated to the primary focus. Metastatic purulent foci form in them.
The sources (primary foci) of pyemia in newborns are most often infections of the umbilical wound (omphalitis ‒ more than 25%), neonatal pneumonia (20-25%), intestinal diseases (ulcerative necrotic enterocolitis – about 20%), etc. Secondary pyemic foci are most often formed in the meninges (purulent meningitis), bones (osteomyelitis), lungs (abscessing pneumonia), soft tissues (phlegmons, skin abscesses).
In 60-70% of adults, the first pyemic foci are formed in the lungs (abscess, lung infarction). When pulmonary veins are involved, septic emboli spread through a large circle of blood circulation – liver abscesses, kidney carbuncles, purulent arthritis, skin abscesses, intermuscular phlegmons, pericarditis, pleural empyema, purulent peritonitis are formed.
Symptoms
The clinical picture consists of a general intoxication syndrome and local manifestations caused by the localization of metastatic foci. Intoxication syndrome is characterized by hectic fever, adynamia, arterial hypotension, headache. Temperature fluctuations occur 3-5 times a day, accompanied by chills, profuse sweats, pronounced tachycardia.
The defeat of the central nervous system in septicopiemia can manifest itself as brain abscess, purulent meningitis, thromboembolic meningoencephalitis. There is a meningeal syndrome, convulsions, possible disturbances of consciousness.
Secondary abscessing pneumonia is accompanied by a cough with purulent sputum, shortness of breath, cyanosis, intermittent fever. It is possible to form multiple lung tissue abscesses, lung gangrene, pleural empyema. Heart damage can take the form of infectious endocarditis, pericarditis, endomyocarditis, which occur with the phenomena of increasing heart failure.
With purulent kidney damage (abscess, carbuncle, paranephritis), there is a pronounced pain syndrome in the lower back, pyuria, urine excretion decreases. The presence of a septic focus in the liver is accompanied by dull pains in the hypochondrium, hepatomegaly, and jaundice of the skin.
Complications
Septicopyemia itself is considered as a complication of sepsis. However, further progression of the infectious process can lead to the development of septic shock. There is a critical decrease in blood pressure, respiratory failure increases, DIC syndrome develops. When abscesses break through into the abdominal cavity, purulent peritonitis occurs, when vessels melt, massive erosive bleeding occurs. The main cause of mortality in septicopiemia is multiple organ dysfunction.
Diagnostics
There are no specific methods for diagnosing septicopyemia. The diagnosis is made based on the combination of clinical, laboratory and instrumental data. A multidisciplinary team of specialists is engaged in the management of patients: surgeons of various specialties, resuscitator, transfusiologist, clinical pharmacologist, etc. Important diagnostic criteria for septicopiemia are:
- Objective data. The general condition is regarded as severe. There is adynamia, lethargy or agitation, there may be convulsions, confusion of consciousness. Fever with chills, arterial hypotension, tachycardia are characteristic. Diuresis is reduced.
- Laboratory indicators. Anemia is detected in the blood, high leukocytosis >12×10⁹ / l, ESR 60 mm / h. Biochemical examination reveals hypoproteinemia, hypoalbuminemia, increased CRP, procalcitonin. Bacteremia is detected in about 70% of cases, therefore, blood for sowing must be taken repeatedly at the height of hyperthermia.
- Signs of generalization of infection. During instrumental examination, pyemic foci of various localization are visualized that are not associated with the entrance gate. To identify them, sonography (echocardiography, ultrasound of the kidneys, liver), radiography (lungs, bones and joints), tomography (CT, MRI), lumbar puncture are performed. In unclear situations, diagnostic laparoscopy or thoracoscopy is resorted to.
Septicopyemia needs to be differentiated from tuberculosis infection, other diseases occurring with febrile syndrome (malaria, typhoid fever, leptospirosis, brucellosis, etc.). Local infections (abscesses, phlegmons), isolated pyelonephritis, pneumonia should also be excluded.
Treatment
Treatment is carried out in a surgical hospital and is of a combined nature. Main directions: elimination of purulent foci, suppression of the infectious process, removal of intoxication syndrome, restoration of immunological homeostasis. Enteral or parenteral nutrition with a high content of protein and vitamins is selected.
Surgical treatment
Rehabilitation of septic foci, both primary and metastatic, involves drainage or excision of abscesses, phlegmon, repeated surgical treatment of wounds, necrectomy. It is necessary to remove internal sources of infection: infected foreign bodies, vascular prostheses, artificial heart valves, joint endoprostheses.
Taking into account the localization of ulcers, drainage of pleural empyema or lung abscess, opening of liver abscesses, kidney carbuncle can be performed. Drains are installed in the body cavity and wounds, flow washing, dressings, local administration of enzymes and antibiotics are carried out. With the localization of purulent foci in the limb area, amputation may be indicated.
Conservative therapy
It is performed in the intensive care unit before and after surgical interventions. It is multidimensional in nature:
- Antibacterial therapy. It is selected in accordance with the selected pathogen or microbial association. Usually, cephalosporins, aminoglycosides, penicillins, fluoroquinolones, carbapenems, metronidazole derivatives are used in the treatment of septicopyemia. The duration of therapy is determined by clinical and laboratory parameters (normalization of t ° and blood parameters, negative backseeds). It is possible not only intravenous, but also intra-arterial, endolymphatic, intraosseous administration of antibiotics.
- Detoxification. It is carried out by infusion therapy under the control of diuresis and hemodynamics. Patients are injected with solutions of glucose, potassium and sodium chloride, plasma substitutes (rheopolyglucin, hemodesis). The use of forced diuresis is shown.
- Immunotherapy. It includes transfusion of freshly frozen donor plasma, administration of immunoglobulins (antistaphylococcal, normal human), staphylococcal toxoid.
- Efferent therapy. Elimination of endotoxins and restoration of homeostasis in sepsis is facilitated by extracorporeal hemocorrection: hemosorption, plasmapheresis, plasma filtration. With the development of acute renal failure, hemodialysis and hemofiltration procedures are resorted to.
Prognosis and prevention
Septicopyemia with the formation of distant purulent dropouts is one of the most severe forms of sepsis and is accompanied by the highest percentage of mortality. Only timely detection and radical rehabilitation of all foci, connection of etiotropic and pathogenetic treatment allow us to hope for a favorable prognosis.
Prevention of septicopiemia is closely related to the provision of qualified surgical care for purulent diseases, injuries, wound infections. It is important to prevent the development of bacteremia and sepsis. In the medical facility, it is necessary to strictly observe the sanitary and hygienic regime, aseptic and antiseptic measures.
