Dear Editor, We read with great interest the editorial written by de Waele and Sakr [1], in which the authors described their pragmatic strategy on how to search the source of a sepsis. It appears of paramount importance to precise that searching for a source of infection does not always mean finding a source of infection. Indeed, the lack of documentation (clinical or microbiological) of a source of infection during the 24 first hours of a septic shock is a common but disturbing and challenging clinical scenario reflected by the classical question “what does my patient have?” often heard during the morning rounds in many ICUs. We recently reported in the Journal the results of a pragmatic multicenter prospective observational cohort study [2] including 508 patients admitted to the ICU for a suspicion of septic shock. It is worth notifying that more than a quarter of them (n = 134/506, 26%) had no source of infection nor microbiological documentation retrieved 24 h after shock onset (defined as the start of vasopressor infusion), despite an exhaustive diagnostic work-up. Indeed, these patients underwent more diagnostic testing with more imaging procedures—including computed tomography of the chest and abdomen and echocardiography—during the first 24 h of shock management, as compared to those with a source of infection identified within the first 24 h of shock. These patients without an “early confirmed septic shock” eventually had either a source of infection or a microbiological documentation retrieved after the 24 first hours (n = 37/134, 28%)—mostly a respiratory, urinary, or abdominal sepsis—or a sepsis mimicker (n = 59/134, 44%)—mostly an adverse event of drugs, an acute mesenteric ischemia, or a malignancy—or a shock of unknown origin (n = 38/134, 28%). Mortality did not differ between patients with an early confirmed septic shock and those with a non early confirmed septic shock. Intensivists should be aware that the absence of a source of infection is not so uncommon in the first 24 h of management of a patient with a suspected septic shock. A source of infection may be diagnosed later, but the hypothesis of a sepsis mimicker should be suspected in such a context.

中文翻译：

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寻找脓毒症来源

亲爱的编辑，我们非常感兴趣地阅读了 de Waele 和 Sakr [1] 撰写的社论，其中作者描述了他们关于如何搜索脓毒症来源的实用策略。寻找感染源并不总是意味着找到感染源，这一点似乎至关重要。事实上，在感染性休克的最初 24 小时内缺乏感染源的文件（临床或微生物学）是一种常见但令人不安和具有挑战性的临床情况，这反映在经典问题“我的病人有什么？” 在许多 ICU 的早晨检查中经常听到。我们最近在该杂志上报道了一项务实的多中心前瞻性观察队列研究的结果 [2]，其中包括 508 名因怀疑感染性休克而入住 ICU 的患者。值得一提的是，尽管进行了详尽的诊断工作，但仍有超过四分之一（n = 134/506，26%）在休克发作（定义为开始输注血管加压药）后 24 小时内没有感染源或微生物记录-向上。事实上，与那些在休克的前 24 小时内确定感染源的患者相比，这些患者在休克治疗的前 24 小时内接受了更多的诊断测试和更多的影像学检查，包括胸部和腹部的计算机断层扫描和超声心动图. 这些没有“早期确诊的感染性休克”的患者最终在最初 24 小时后找到了感染源或微生物学文件（n = 37/134，28%）——主要是呼吸道、泌尿系统或腹部脓毒症——或脓毒症模仿者（n = 59/134，44%）——主要是药物不良事件、急性肠系膜缺血或恶性肿瘤——或不明原因的休克（n = 38/134，28%）。早期确诊感染性休克患者和非早期确诊感染性休克患者的死亡率没有差异。重症监护医师应该意识到，在对疑似感染性休克患者进行治疗的最初 24 小时内，没有感染源的情况并不少见。稍后可能会诊断出感染源，但在这种情况下应该怀疑脓毒症模仿者的假设。重症监护医师应该意识到，在对疑似感染性休克患者进行治疗的最初 24 小时内，没有感染源的情况并不少见。稍后可能会诊断出感染源，但在这种情况下应该怀疑脓毒症模仿者的假设。重症监护医师应该意识到，在对疑似感染性休克患者进行治疗的最初 24 小时内，没有感染源的情况并不少见。稍后可能会诊断出感染源，但在这种情况下应该怀疑脓毒症模仿者的假设。