Essential History for Septic Shock Patients
A comprehensive history must be obtained rapidly and systematically to guide appropriate empiric antimicrobial therapy, as failure to initiate appropriate therapy is associated with a substantial increase in morbidity and mortality. 1
Critical Historical Elements to Extract
Source and Site of Infection
- Nature of clinical syndrome/site of infection - identify whether respiratory (pneumonia), abdominal, urinary, skin/soft tissue, or other source, as this determines pathogen profile and antimicrobial penetration requirements 1
- Timing and location of infection acquisition - distinguish between community-acquired, healthcare-associated (chronic care facility), or hospital-acquired (nosocomial), as this dramatically affects likely pathogens and resistance patterns 1
Medical History Affecting Pathogen Risk
- Underlying diseases and chronic organ failures - diabetes, malignancy, liver disease, renal failure, as these increase infection susceptibility and affect antimicrobial choices 1
- Immunosuppression status - neutropenia, HIV/AIDS, splenectomy, chronic steroid use, chemotherapy, transplant status, or congenital/acquired immunodeficiencies, as these predispose to atypical and resistant pathogens including Candida species 1, 2
- Recent known infection or colonization - particularly with multidrug-resistant organisms like MRSA or vancomycin-resistant Enterococci 1
Medication and Treatment History
- Antimicrobial use within previous 3 months - critical for predicting resistance patterns and selecting alternative agents 1
- Current medications - identify potential drug interactions, intolerances, and medications affecting immune function 1
- Indwelling devices - central venous catheters, urinary catheters, endotracheal tubes, prosthetic joints, cardiac devices, as these compromise host defenses 1
Risk Factors for Resistant Pathogens
- Prolonged hospitalization or chronic facility stay - increases exposure to resistant organisms 1
- Prior hospitalization - particularly within the past 90 days 1
- Prior colonization or infection with multidrug-resistant organisms - documented MRSA, extended-spectrum beta-lactamase (ESBL) producers, carbapenem-resistant organisms 1
Demographics and Host Factors
- Age - infants and elderly persons have increased sepsis risk and may present atypically 1, 2
- Race - Black race is associated with higher sepsis risk 1
- Gender - males have higher sepsis incidence 1
- Comorbidities - chronic diseases such as malignancy significantly affect sepsis course and outcomes 2
Common Pitfalls to Avoid
Do not delay antimicrobial administration to obtain a complete history - the first dose should be given within 1 hour while simultaneously gathering historical information 3. Failure to initiate appropriate empiric therapy rapidly increases mortality as much as fivefold 1.
Do not overlook recent antibiotic exposure - this is one of the most critical historical elements, as it predicts resistance patterns and necessitates broader coverage or alternative agents 1.
Do not assume community-acquired infections lack resistant organisms - patients with recent healthcare exposure, chronic care facility residence, or prior resistant organism colonization require broader empiric coverage despite presenting from the community 1.
Do not forget to assess for potential drug allergies and intolerances - this must be balanced against the need for appropriate coverage, as true severe allergies are rare and inappropriate therapy is more dangerous than most allergic reactions 1.