SOME DIFFERENCES IN THE DIAGNOSIS AND TREATMENT OF GRAM-POSITIVE AND GRAM-NEGATIVE SEPSIS
Authors: Shapoval S. D. 
Published: February 2025

Summary. The course of gram-positive and gram-negative sepsis has significant differences that should be taken into account when conducting complex treatment. Mortality in such patients remains very high, and hospital stay requires significant material costs.
The aim of the study. To find out the differences between clinical and laboratory signs of gram-positive and gram-negative sepsis and the features of their course. Materials and methods. A study was conducted of 317 patients with sepsis who were examined and treated in the city purulent-septic centre of Zaporizhzhia in the period 1991- 2024. In all cases, community-acquired sepsis was observed, i.e. sepsis that developed within 48 hours of the patient’s hospital stay. Two main groups were formed: 1 — patients with gram(+) sepsis (168 patients — 53%), 2 — patients with gram(-) sepsis (149 pati-ents — 47%). In addition, within each group, two subgroups were formed: those treated in 1991-2016 (subgroup I) — 235 patients, and subgroup II — in 2017-2024 — 82 patients. Among sepsis, the uncomplicated form of the disease was noted in 208 patients (65.6 %), and septic shock (SS) — 109 patients (34.4 %).
Result. The bulk of patients in both the first and second groups were young people, 81.7 % and 77.4 %, respectively, i.e. able-bodied. Sepsis occurred in 82 % of cases (260 patients) against the background of concomitant diseases, which in 74.5 % (236 patients) had signs of decompensation. The etiological picture of sepsis changed dynamically. Thus, at the beginning of the study (1991-2004), the prevalence of gram(-) flora in the development of sepsis was noted. At present, gram(+) flora and, accordingly, gram(+) sepsis prevail. It was found that the severity of the condition of patients admitted to the hospital was directly related to the timing of the first manifestations of the disease. The development of gram(+) sepsis was generally «gradual», while gram(-) sepsis developed more rapidly and was «malignant». The primary purulent focus almost always coincided with the entrance gate of the infection. In 32 patients (10.1%) with gram(+) sepsis, there were secondary (metastatic) pyogenic foci in various organs and tissues remote from the site of infection, while in patients with gram(-) sepsis, there were no secondary metastatic purulent foci. In purulent-necrotic lesions up to 150 cm2, the development of gram-positive sepsis was most often noted — 38.1% (59 patients) versus 32.1% (52 patients) of patients in group 2. On the contrary, gram-negative sepsis was significantly (P < 0.05) more common if the area of purulent-necrotic lesion exceeded 300 cm2. The microbial contamination of primary purulent foci in patients with both gram(+) and gram(-) sepsis was high: in 78.2% of patients in the first group and 82.3% in the second group, the number of microbes in the PFO tissues exceeded the «critical» level. In patients with gram(-) sepsis, the number of patients with microbial contamination of PGO exceeding the «critical» level was significantly (107–1012 per 1 g of tissue) higher (P < 0.05) than in patients of group 1: 53.2% vs. 34.7%, respectively. Hypothermia, fever, decreased systolic and diastolic blood pressure, anaemic syndrome, accelerated ESR, more pronounced changes in the general urine analysis were significantly (P < 0.05) more common than in patients with gram (+) sepsis. There was no dependence of target organ damage on the etiology of sepsis, except for one indicator - hypoproteinaemia. The latter was more pronounced (P < 0.05) in patients with gram(-) sepsis than in patients with gram(+) sepsis. Positive results of blood cultures ranged from 12.8 to 32.3% in gram(+) sepsis and from 8.9 to 17.8% in gram(-) sepsis. The duration of ABT was determined in each case depending on the level of procalcitonin, the severity of the patient’s condition, and the severity of signs of intoxication. As a result of the proposed schemes of complex intensive care for patients with sepsis, mortality in the group of patients with gram(+) sepsis decreased from 19.4 to 17.1%, in gram(-) sepsis — from 24.4 to 20.5%, and the average length of stay in the hospital decreased from (31.2 + 4.3) days to (26.6 + 3.7) in the first group and from (37.4 + 2.9) to (29.3 + 4.2) da-ys in the second group.
Conclusions. The development of gram(+) sepsis is generally «gradual», whereas gram(-) sepsis develops more rapidly and is «malignant». The differences in the course of gram(+) and gram(-) sepsis make it possible to prescribe etiotropic therapy in a targeted manner. In patients with a diagnosis of SS and adequate control of the source of infection, shorter rather than longer antimicrobial therapy should be used. The optimal regimen for ABT is the use of carbapenems in the highest dosage in combination with linezolid.