Sepsis Diagnostic Algorithm
Diagnosis is based on international consensus. If a patient with suspected infection (including purulent mastitis) deteriorates, the following algorithm is applied:
- Step 1. Assessment using the qSOFA score. If the score is $\ge$ 2 points, proceed to the next step. If less than 2 points, but suspicion remains, continue close monitoring.
- Step 2. Assessment of organ dysfunction using the SOFA score. A total score of $\ge$ 2 points officially confirms a diagnosis of sepsis.
- Step 3. Assessment during adequate fluid resuscitation. If vasopressors are required to maintain a mean arterial pressure (MAP) $\ge$ 65 mm Hg, and lactate levels exceed 2.0 mmol/L, septic shock is diagnosed. If these criteria are not met, the condition is classified as sepsis.
Surgical tactics and focus debridement
Sanitation of the infectious focus is performed as early as possible concurrently with intensive care. In purulent mastitis or an infected wound, wide incision and drainage (evacuation) is indicated.
It is important to consider diagnostic specifics: in 40% of cases, the source of infection is only presumed, and classic local symptoms may be absent. The clinical presentation is often dominated by worsening multiple organ dysfunction syndrome (MODS). Underestimating the absence of local symptoms leads to delayed surgery, which critically reduces survival rates.
If the infection involves the uterus (endomyometritis), curettage and lavage are performed. Hysterectomy is considered only if MODS progresses, therapy fails, and the uterus is the sole source determining the severity of the condition. Extirpation without strict indications may further deteriorate the patient's condition.
Intensive care: The time rule
Treatment of septic conditions is carried out in the ICU. Priority measures include central venous catheterization, insertion of a urinary catheter to monitor diuresis, and blood sampling.
- Fluid resuscitation: initiated with crystalloids (up to 30 mL/kg). If ineffective, albumin is administered. The goals of fluid therapy are detoxification, improved tissue perfusion, restoration of acid-base balance, and reduced blood viscosity for better antibiotic delivery.
- Antibiotic therapy: broad-spectrum drugs (monotherapy or combination) are administered simultaneously with the initiation of fluid resuscitation. The regimen is adjusted after blood culture results are obtained.
Target parameters and timing
Within the first 3 hours, lactate levels must be determined. If fluid therapy is ineffective, vasopressor support (norepinephrine, occasionally with epinephrine or vasopressin) is prescribed to achieve a MAP > 65 mm Hg. If there is no response to vasopressors, water-soluble hydrocortisone is administered (up to 200 mg/day). If the cardiac index falls < 2.5 L/min/m², inotropic support (dobutamine, levosimendan) is indicated.
By 6 hours post-diagnosis, the infectious focus must be debrided, and hemodynamic parameters must reach target values:
- Central venous pressure (CVP): 8–12 mm Hg
- Mean arterial pressure (MAP): $\ge$ 65 mm Hg
- Mixed venous oxygen saturation (SvO₂): $\ge$ 65%
- Diuresis: $\ge$ 0.5 mL/kg/h
Supportive care and detoxification
Comprehensive treatment includes several areas:
- Respiratory support: ranging from mask oxygen therapy to mechanical ventilation if acute respiratory distress syndrome develops.
- Hemostasis correction: fresh frozen plasma for consumption coagulopathy, low-molecular-weight heparin for thrombosis prophylaxis, and activated protein C for MODS with hypoperfusion.
- Nutritional support: enteral nutrition (fat emulsions, proteins, glucose) with strict glycemic control (4.5–6.1 mmol/L). Insulin is administered as needed.
- Extracorporeal methods: used according to indications and include hemodialysis (especially for renal failure), hemofiltration, plasmapheresis, and various types of sorption.
- Prophylaxis: proton pump inhibitors are used to prevent stress ulcers of the gastrointestinal tract.
Briefly: answers to topical questions
Which microorganisms are the most common causative agents of postpartum mastitis?
Staphylococcus aureus is most frequently the causative agent of postpartum mastitis. In 80% of cases, it is identified as a monoculture or in association with the following microorganisms:
- Escherichia coli (Escherichia coli) — a Gram-negative bacterium;
- Pseudomonas aeruginosa — a Gram-negative bacterium.
The inflammatory process can also be caused by other opportunistic Gram-negative bacteria. Overall, postpartum purulent-septic diseases frequently present as mixed infections with an increasing role of non-spore-forming anaerobic bacteria.
Which specific antibiotic groups are used for initial empiric therapy of postpartum mastitis?
Broad-spectrum penicillin antibiotics are used for the treatment of postpartum mastitis. Breastfeeding may be continued while taking these drugs.
If anaerobic pathogens are identified, the following antibacterial drugs are prescribed:
- Lincomycin
- Clindamycin
- Gentamicin
- Rifampicin
The subsequent treatment regimen is adjusted after receiving the results of milk bacteriological culture, taking into account microorganism susceptibility.
Which clinical forms (stages) of postpartum mastitis are distinguished by the nature of the inflammatory process?
Based on the nature of the inflammatory process, three main clinical forms of postpartum mastitis are distinguished:
- Serous — early-stage mastitis.
- Infiltrative.
- Purulent.
Purulent mastitis is further subdivided into infiltrative-purulent (diffuse and nodular), abscess-forming (furunculosis or areolar abscess, abscess within or behind the mammary gland), phlegmonous (purulent-necrotic), and gangrenous.
What classic local symptoms are characteristic of purulent mastitis?
Purulent forms of mastitis are characterized by specific local symptoms depending on the stage of destruction:
- Infiltrative-purulent mastitis — an infiltrate with areas of softening is palpable, with pronounced tissue edema over the inflammatory focus.
- Abscess-forming mastitis — a sharply painful infiltrate with a cavity and a positive fluctuation sign are identified.
- Phlegmonous mastitis — significant enlargement of the gland, involvement of 3–4 quadrants, skin is markedly hyperemic and tense, cyanotic in places; a "peau d'orange" (lemon peel) sign may be present.
- Gangrenous mastitis — skin necrosis and purulent melting of underlying tissues.
General local signs remain enlargement, hyperemia, and sharp tenderness of the gland.
What ultrasound features are characteristic of purulent postpartum mastitis?
On ultrasound examination, purulent postpartum mastitis is characterized by specific features depending on the form of the disease. In purulent mastitis, dilated ducts and alveoli are visualized, surrounded by a zone of infiltration, creating a characteristic "honeycomb" pattern.
The abscess-forming form is typically characterized by anechoic structures and visualization of a cavity with irregular edges and septae. A thickened abscess capsule and signs of surrounding tissue edema are also identified.
To memorize the criteria for septic shock, use the rule "Two 65s and lactate": MAP $\ge$ 65 mm Hg (requiring vasopressors), venous oxygen saturation $\ge$ 65% (target by 6 hours), and lactate greater than 2 mmol/L.
Class and exam questions
What does the surgical treatment of purulent mastitis involve?
Wide opening and adequate drainage (evacuation) of the purulent focus are performed. Debridement must be carried out as early as possible against the background of intensive care.
What drugs are used for initial infusion therapy in sepsis?
First-line drugs are crystalloids in a volume of up to 30 ml/kg. If they are ineffective, human albumin solution is used.
When are corticosteroids prescribed in septic shock?
Water-soluble hydrocortisone at a dose of no more than 200 mg/day intravenously is prescribed exclusively in cases where vasopressors are ineffective.
What are the target blood glucose levels during nutritional support?
The target glucose level is 4.5–6.1 mmol/L. To maintain it during intravenous dextrose administration, insulin is used according to indications.
What else to study on this topic
- Classification of postpartum purulent-septic diseases
- Diagnostic criteria for various forms of mastitis
- Breastfeeding in mastitis: indications and contraindications
- Clinical presentation and diagnosis of postpartum endometritis
- Clinical features of obstetric peritonitis
- Indications for hysterectomy in sepsis
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