in treatment of septic shock. trials are ongoing and it is currently being used in japan and western europe. recombinant activated protein c (drotrecogin alpha) in a 2011 cochrane review was found not to decrease mortality and to increase bleeding, and thus, was not recommended for use. drotrecogin alfa (xigris), was withdrawn from the market in october 2011. epidemiology sepsis has a worldwide incidence of more than 20 million cases a year, with mortality due to septic shock reaching up to 50 percent even in industrialized countries. according to the u.s. centers for disease control, septic shock is the thirteenth leading cause of death in the united states and the most frequent cause of death in intensive care units. there has been an increase in the rate of septic shock deaths in recent decades, which is attributed to an increase in invasive medical devices and procedures, increases in immunocompromised patients, and an overall increase in elderly patients. tertiary care centers (such as hospice care facilities) have 2-4 times the rate of bacteremia than primary care centers, 75% of which are hospital-acquired infections. the process of infection by bacteria or fungi may result in systemic signs and symptoms that are variously described. approximately 70% of septic shock cases were once traceable to gram-negative bacteria that produce endotoxins, however, with the emergence of mrsa and the increased use of arterial and venous catheters, gram-positive bacteria are implicated approximately as commonly as bacilli. in rough order of increasing severity these are, bacteremia or fungemia; sepsis, severe sepsis or sepsis syndrome; septic shock, refractory septic shock, multiple organ dysfunction syndrome, and death. 35% of septic shock cases derive from urinary tract infections, 15% from the respiratory tract, 15% from skin catheters (such as ivs), and more than 30% of all cases are idiopathic in origin. the mortality rate from sepsis, especially if it is not treated rapidly with the needed medications in a hospital, is approximately 40% in adults and 25% in children. it is significantly greater when sepsis is left untreated for more than seven days.