Michael Filbin, M.D. is an attending physician and Director of Clinical Research in emergency medicine at Massachusetts General Hospital. His research specialty is sepsis and severe infection, and he serves on the Massachusetts Sepsis Consortium’s Special Task Force on Emergency Medicine. Dr. Filbin recently talked with Patient Safety Beat about the challenge of managing diagnosis and treatment of COVID-19, flu and sepsis — three conditions with similar symptoms — during the pandemic.
Betsy Lehman Center: What do we know about the relationship of sepsis to COVID-19? Are patients who are critically ill with COVID-19 also the ones more likely to develop sepsis?
Dr. Filbin: In a way, severe COVID-19 is sepsis; it’s a form of viral sepsis. We typically think of sepsis as originating from bacterial infections, yet viral sepsis has always existed. Sepsis is any infection that leads to organ dysfunction, and patients with severe COVID-19 certainly have organ dysfunction. Similar to influenza, COVID-19 “sepsis” mainly attacks lung tissue, and more aggressively as we have seen, but it can and does spread throughout the body infecting other tissues as well, causing organ damage similar to bacterial sepsis. In addition to effecting the lung, COVID-19 can lead to heart, kidney, liver and neurological dysfunction as well.
There is certainly overlap between patients critically ill with COVID-19 and those more likely to develop sepsis. In particular, older age is a major risk factor for severe illness and death in both conditions. However, during the COVID-19 surge we saw a disproportionate number of patients in their 40s, 50s, and early 60s – younger than typical bacterial sepsis patients – who were critically ill with COVID-19 and requiring intubation. Fortunately, most of those patients recovered eventually and survived, although some after a long rocky course.
Betsy Lehman Center: As an emergency physician, how are you approaching the diagnostic challenges posed by the need to differentiate flu, COVID-19 and sepsis?
Dr. Filbin: When the flu was still around last spring, during the beginning of the surge, we would test for both flu and COVID-19. However, we saw very few flu cases in comparison to COVID-19, so we stopped testing for it. When flu makes a resurgence this fall, we will simply test for both. From a treatment perspective, it is often a judgement call whether to initiate broad-spectrum antibiotics (treatment for bacterial sepsis) in patients with COVID-19 with the typical pneumonia seen on chest x-ray. The question is whether patients with COVID-19 pneumonia can be co-infected with bacteria and benefit from antibiotics. The World Health Organization recommends withholding antibiotics in patients with mild to moderate COVID-19 unless bacterial infection is particularly suspected, and to give antibiotics as we would for bacterial sepsis in severe cases of COVID-19 that require ICU admission or mechanical ventilation.
Betsy Lehman Center: What about patients and families? There is potential for confusion there as well, given overlapping symptoms of flu, COVID-19 and sepsis. What is the best advice for them?
Dr. Filbin: I urge patients and families to contact their doctor if they have symptoms or observe signs that could be related COVID-19 or flu (fevers, chills, malaise, cough, shortness of breath, feeling unwell) and get tested. The cardinal signs of severe disease might be similar in both COVID-19 and sepsis — difficulty catching your breath, confusion, low blood pressure, or becoming pale or very weak — and this should prompt patients to seek immediate attention in their local emergency department.