In recent years, the importance of gram-negative organisms in the genesis of sepsis has been emphasized. However, this emphasis may no longer be correct; recent studies show an increasing incidence of gram-positive sources of sepsis, and it is possible that these cases may predominate in the coming years. This increase results from more than just a greater prevalence of infection—it appears that gram-positive organisms may also be more virulent in fomenting the disease, as can be evidenced by the emergence of streptococcal toxic shock syndrome and the resurgence of acute rheumatic fever. This may result from the ability of gram-positive organisms to produce more inflammation-causing cell wall constituents, as well as unbound exotoxins. Despite the recent emphasis on gram-negative causes, sepsis resulting from gram-positive sources is increasingly common. Research on these causes of sepsis should be encouraged.
(Arch Intern Med. 1994;154:26-34)