A41.2 - Sepsis due to unspecified staphylococcus

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

• Sepsis caused by Staphylococcus without acute organ dysfunction
• Sepsis due to Staphylococcus
• Septic myocarditis - staphylococcal
• Septic shock co-occurrent with acute organ dysfunction due to Gram-positive coccus
• Septic shock co-occurrent with acute organ dysfunction due to Staphylococcus

Clinical Information

• Burkholderia Infections-. infections with bacteria of the genus burkholderia.
• Lemierre Syndrome-. a superinfection of the damaged oropharyngeal mucosa by fusobacterium necrophorum leading to the secondary septic thrombophlebitis of the internal jugular vein.
• Neonatal Sepsis-. blood infection that occurs in an infant younger than 90 days old. early-onset sepsis is seen in the first week of life and most often appears within 24 hours of birth. late-onset occurs after 1 week and before 3 months of age.
• Pregnancy Complications, Infectious-. the co-occurrence of pregnancy and an infection. the infection may precede or follow fertilization.
• Puerperal Infection-. an infection occurring in puerperium, the period of 6-8 weeks after giving birth.
• Sepsis-. systemic inflammatory response syndrome with a proven or suspected infectious etiology. when sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. when sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock.
• Sepsis-Associated Encephalopathy-. acute neurological dysfunction during severe sepsis in the absence of direct brain infection characterized by systemic inflammation and blood brain barrier perturbation.
• Systemic Inflammatory Response Syndrome-. a systemic inflammatory response to a variety of clinical insults, characterized by two or more of the following conditions: (1) fever >38 degrees c or hypothermia <36 degrees c; (2) tachycardia >90 beat/minute; (3) tachypnea >24 breaths/minute; (4) leukocytosis >12,000 cells/cubic mm or 10% immature forms. while usually related to infection, sirs can also be associated with noninfectious insults such as trauma; burns; or pancreatitis. if infection is involved, a patient with sirs is said to have sepsis.
• Burkholderia-. a genus of gram-negative, aerobic, rod-shaped bacteria originally classified as members of the pseudomonadaceae.

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Patient Education

Sepsis

What is sepsis?

Sepsis is your body's overactive and extreme response to an infection. Sepsis is a life-threatening medical emergency. Without quick treatment, it can lead to tissue damage, organ failure, and even death.

What causes sepsis?

Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Bacterial infections are the most common cause, but other types of infections can also cause it.

The infections are often in the lungs, stomach, kidneys, or bladder. It's possible for sepsis to begin with a small cut that gets infected or with an infection that develops after surgery. Sometimes, sepsis can occur in people who didn't even know that they had an infection.

Who is at risk for sepsis?

Anyone with an infection could get sepsis. But certain people are at higher risk:

• Adults 65 or older
• People with chronic conditions, such as diabetes, lung disease, cancer, and kidney disease
• People with weakened immune systems
• Pregnant women
• Children younger than one

What are the symptoms of sepsis?

Sepsis can cause one or more of these symptoms:

• Rapid breathing and heart rate
• Shortness of breath
• Confusion or disorientation
• Extreme pain or discomfort
• Fever, shivering, or feeling very cold
• Clammy or sweaty skin

It's important to get medical care right away if you think you might have sepsis or if your infection is not getting better or is getting worse.

What other problems can sepsis cause?

Severe cases of sepsis can lead to septic shock, where your blood pressure drops to a dangerous level and multiple organs can fail.

How is sepsis diagnosed?

Your health care provider may use many tools to make a diagnosis:

• A medical history, which includes asking about your symptoms
• A physical exam, including checking vital signs (your temperature, blood pressure, heart rate, and breathing)
• Lab tests that check for signs of infection or organ damage
• Imaging tests such as an x-ray or a CT scan to find the location of the infection

Many of the signs and symptoms of sepsis can also be caused by other medical conditions. This may make sepsis hard to diagnose in its early stages.

What are the treatments for sepsis?

It is very important to get treatment right away. Treatment usually includes:

• Antibiotics
• Maintaining blood flow to organs. This may involve getting oxygen and intravenous (IV) fluids.
• Treating the source of the infection
• If needed, medicines to increase blood pressure

In serious cases, you might need kidney dialysis or a breathing tube. Some people need surgery to remove tissue damaged by the infection.

Can sepsis be prevented?

To prevent sepsis, you should try to prevent getting an infection:

• Take good care of any chronic health conditions that you have
• Get recommended vaccines
• Practice good hygiene, such as handwashing
• Keep cuts clean and covered until healed

NIH: National Institute of General Medical SciencesCenters for Disease Control and Prevention

Staphylococcal Infections

What are Staphylococcal (staph) infections?

Staphylococcus (staph) is a group of bacteria. There are more than 30 types. A type called Staphylococcus aureus causes most infections.

Staph bacteria can cause many different types of infections, including:

• Skin infections, which are the most common types of staph infections
• Bacteremia, an infection of the bloodstream. This can lead to sepsis, a very serious immune response to infection.
• Bone infections
• Endocarditis, an infection of the inner lining of the heart chambers and valves
• Food poisoning
• Pneumonia
• Toxic shock syndrome (TSS), a life-threatening condition caused by toxins from certain types of bacteria

What causes staph infections?

Some people carry staph bacteria on their skin or in their noses, but they do not get an infection. But if they get a cut or wound, the bacteria can enter the body and cause an infection.

Staph bacteria can spread from person to person. They can also spread on objects, such as towels, clothing, door handles, athletic equipment, and remotes. If you have staph and do not handle food properly when you are preparing it, you can also spread staph to others.

Who is at risk for staph infections?

Anyone can develop a staph infection, but certain people are at greater risk, including those who:

• Have a chronic condition such as diabetes, cancer, vascular disease, eczema, and lung disease
• Have a weakened immune system, such as from HIV/AIDS, medicines to prevent organ rejection, or chemotherapy
• Had surgery
• Use a catheter, breathing tube, or feeding tube
• Are on dialysis
• Inject illegal drugs
• Do contact sports, since you may have skin-to-skin contact with others or share equipment

What are the symptoms of staph infections?

The symptoms of a staph infection depend on the type of infection:

• Skin infections can look like pimples or boils. They may be red, swollen, and painful. Sometimes there is pus or other drainage. They can turn into impetigo, which turns into a crust on the skin, or cellulitis, a swollen, red area of skin that feels hot.
• Bone infections can cause pain, swelling, warmth, and redness in the infected area. You may also have chills and a fever.
• Endocarditis causes some flu-like symptoms: fever, chills, and fatigue. It also causes symptoms such as rapid heartbeat, shortness of breath, and fluid buildup in your arms or legs.
• Food poisoning typically causes nausea and vomiting, diarrhea, and a fever. If you lose too many fluids, you may also become dehydrated.
• Pneumonia symptoms include a high fever, chills, and cough that doesn't get better. You may also have chest pain and shortness of breath.
• Toxic shock syndrome (TSS) causes high fever, sudden low blood pressure, vomiting, diarrhea, and confusion. You may have a sunburn-like rash somewhere on your body. TSS can lead to organ failure.

How are staph infections diagnosed?

Your health care provider will do a physical exam and ask about your symptoms. Often, providers can tell if you have a staph skin infection by looking at it. To check for other types of staph infections, providers may do a culture, with a skin scraping, tissue sample, stool sample, or throat or nasal swabs. There may be other tests, such as imaging tests, depending on the type of infection.

What are the treatments for staph infections?

Treatment for staph infections is antibiotics. Depending on the type of infection, you may get a cream, ointment, medicines (to swallow), or intravenous (IV). If you have an infected wound, your provider might drain it. Sometimes you may need surgery for bone infections.

Some staph infections, such as MRSA (methicillin-resistant Staphylococcus aureus), are resistant to many antibiotics. There are still certain antibiotics that can treat these infections.

Can staph infections be prevented?

Certain steps can help to prevent staph infections:

• Use good hygiene, including washing your hands often
• Don't share towels, sheets, or clothing with someone who has a staph infection
• It's best not to share athletic equipment. If you do need to share, make sure that it properly cleaned and dried before you use it.
• Practice food safety, including not preparing food for others when you have a staph infection
• If you have a cut or wound, keep it covered

Code History

• FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
• FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
• FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
• FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
• FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
• FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
• FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
• FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016 (First year ICD-10-CM implemented into the HIPAA code set)