Expert: Severe COVID-19 Illness Is Viral Sepsis

Sepsis is a life-threatening immune response to infection that leads to organ dysfunction, which is what happens in seriously ill COVID-19 patients, expert says.

Seriously ill COVID-19 patients are technically afflicted with sepsis, a national sepsis expert says.

Sepsis is the leading cause of death in U.S. hospitals. Sepsis is a costly condition, with costs for acute sepsis hospitalization and skilled nursing estimated at $62 billion annually.

Seriously ill COVID-19 patients have viral sepsis, Steven Simpson, MD, professor of pulmonary and critical care medicine at The University of Kansas in Kansas City and medical adviser for the Sepsis Alliance, recently told HealthLeaders.

"Sepsis is life-threatening organ dysfunction due to a dysregulated host response to an infection. In COVID-19 sepsis, the infection is the virus, and the life-threatening organ dysfunction is all the organs that can dysfunction, including lungs, brain, kidneys, heart, and liver. These are all organs that are classically associated with sepsis. COVID-19 that causes organ dysfunction is viral sepsis," he said.

Related: How 2 Health Systems Lowered Sepsis Mortality

Sepsis can be caused by bacterial, fungal, and viral infections, and sepsis linked to viral infections is relatively common, Simpson said.

"In addition to the novel coronavirus, there are multiple other viruses that are linked to sepsis. Every year, thousands of people die from influenza sepsis. If you are immunocompromised, there are several herpetic viruses that cause sepsis. For example, if you are undergoing chemotherapy, there are several different viruses that can cause sepsis. We see viral sepsis all the time," he said.

COVID-19 sepsis is more deadly than most forms of bacterial sepsis, Simpson said. "One of the problems with this illness is that it is not like a bacterial sepsis; where if you intervene with appropriate antibiotics early in the course of a bacterial sepsis, you can definitely keep it from progressing. We don't have that capability with COVID-19."

COVID-19 sepsis has a high mortality rate, he said. "For COVID-19 patients who require ICU care, by definition, nearly all of them have sepsis. And we know the mortality rate for COVID-19 patients in ICUs is in the range of 30%–40%."

Limited treatment options

COVID-19 sepsis is deadly because there are few available therapies beyond supportive care, Simpson said.

"So far, we have remdesivir, which can shorten the duration of illness but does not save lives as far as we can tell. We have dexamethasone, which is an immunosuppressant. Presumably, what dexamethasone is doing is calming the host response to the coronavirus infection, and that does seem to help save lives. And the FDA recently gave approval to bamlanivimab—a monoclonal antibody to the virus. Bamlanivimab is for people who have mild illness who are not hypoxemic—they do not need oxygen. It looks like this therapy might prevent the need for hospitalization," he said.

Dexamethasone has shown the most promise in combatting COVID-19 sepsis, Simpson said. "Once a COVID-19 patient has developed sepsis, we know that bamlanivimab and remdesivir are not going to be particularly effective at that point. Dexamethasone has been shown to be useful in septic COVID-19 patients—particularly patients who have been placed on mechanical ventilation."

At this point, illness prevention is the best strategy to address COVID-19 sepsis, he said.

"If you want to prevent sepsis from COVID-19, you must prevent COVID-19. Clinicians all understand the utility of wearing masks, washing hands, and distancing ourselves from one another when we can. We need our patients to understand that. This is a definite case where prevention is the key, and it is why we are exploding all over the nation with COVID-19 because many people will not follow these simple recommendations."

Sepsis awareness

A recent Sepsis Alliance survey gauged awareness of sepsis in the United States. The survey collected data from more than 2,000 adult Americans.

The survey has several key findings.

• Although sepsis is common in severe cases of COVID-19, only 34% of survey respondents were aware that sepsis is a possible complication.
   
• 71% of survey respondents were aware of the term sepsis, which is a six percentage-point increase from the Sepsis Alliance's 2019 survey.
   
• There are stark racial disparities in sepsis awareness. Only 49% of people who identified as black were aware of the term sepsis; 63% of people who identified as Hispanic were aware of the term; and 76% of people who identified as white were aware of the term.
   
• Only 15% of adults could identify the four common signs and symptoms of sepsis, and one-quarter did not know any of the symptoms. The four primary symptoms of sepsis are fever, infection, mental decline, and extreme illness.
   
• There are disparities in sepsis awareness based on income: 79% of people who make an annual income of $75,000 or more are aware of the term, but only 64% of people who make $50,000 or less are aware of the term.