Bacteraemia & Sepsis

Question 1

Toxic Shock syndrome: About

Answer 1

EXOTOXINS –> overwhelming multisystem inflamm (Tcell)
- Fever
- Distributive shock
- Erythroderma
–> after days, desquamating rash.

S. AUREUS
- Any source
- Vaginal colonisation + tampons/ childbirth/TOP
- Benign-looking wound infection
- Very surviveable (<3% mortality)

Less commonly: S. PYOGENES (GAS).
- Nec fasc
- More fatal + (20% mortality)

Blood cultures rarely positive (not usually bacteraemic)

Question 2

Toxic Shock Syndrome: Ix and Management

Answer 2

Ix
- Swab throat (strep), nose (staph) and vagina (both) + any other source

MANAGEMENT
- Aggressive support (fluids, inotropes)
- Source control
- Antibiotics: do not affect the current illness. Are to prevent recurrence.
–> Staph: FLUCLOX + VANC + CLINDA
- IVIG if severe

Question 3

CDC criteria for toxic shock syndrome:

Answer 3

STAPH
1- Fever
2- Rash
3- Desquamation
4- Hypotension
5- >3 systems involved
6- Tests for other causes negative

STREP
Confirmed GAS + hypotension + MODS

Question 4

SIRS Criteria:

Answer 4

Temp >38, <36
PR >90
RR >20 (or PaCO2 <32)
WCC
- >12
- <4
- > 10% bands (immature neuts)

Question 5

Definition of septic SHOCK?

Answer 5

Sepsis (infection + SIRS)

+

Hypotension requiring pressors to maintain MAP >65 and/or lactate >2

Question 6

What are the ‘Rules & Tools’ used in sepsis:

Answer 6

Screening= SIRS, MEWS, NEWS

Mortality Prediction= Quick SOFA
(more complex SOFA or APACHE used in ICU)
“HAT”
- Hypotension <100
- ALOC
- Tachypnoea >22

Question 7

What are the components of sepsis treatment and management, as per the 2021 Surviving Sepsis Guidelines:

Answer 7

FLUIDS
- ‘Balanced’ crystalloid (CSL, PlasmaLyte)
- At least 30ml/kg in first 3 hours
- No more 2-3L (unless specific circ)
- Consider Albumin (4%, 20%), at max fluids
- Restrictive vs liberal? No evidence

PRESSORS
- 1 Norad
- 2 ADD vasopressin
- 3 ADD adrenaline
- Dopamine = mortality

ANTIBIOTICS
- Within 1 hour
- Consider MRSA, fungal cover
- B lactams best if load –> infusion

SOURCE CONTROL
- ASAP
- Including removing indwelling intravascular devices

STEROIDS
- 100mg Hydrocortisone IV, then 50mg Q6H
- If not responsive at 4 hours of filling/pressor
- For ALL on chronic steroids

GLYCAEMIC CONTROL
- Insulin if BSL >10

OTHER
- Sodi Bic for pH <7.2 AND AKI only
- Central access + monitoring
- Frequent dynamic reassessment
- FAST-HUGS including VTE prophylaxis
- If ICU, within 6 hours

Question 8

What is ‘Early Goal Directed Therapy’ in sepsis, and is it recommended?

Answer 8

In first 6 hours, aggressively targeting:

MAP
CVP
Urine output
Haematcrit
Central venous O2

…ARISE/ PROCESS/ PROMISE all showed no benefit to EGDT over standard care. (90 day mortality same)

Question 9

Empirical antibiotics in Sepsis:
- Adult
- Penicillin allergy
- Gent CI
- MRSA
- Tropical

Answer 9

Adult
- FLUCLOX 2g Q6H + GENTAMICIN 5mg/kg

Penicillin allergy
- CEPHAZOLIN or VANCOMYCIN + GENT

Gent contraindicated incl CHILD >2mo
- FLUCLOX + CEFTRIAXONE

MRSA
- ADD VANCOMYCIN 1.5g BD

Tropical
- MEROPENAM

Question 10

5 groups that may need antifungal cover:

Answer 10

HIV
Transplant
Long-term high dose steroids
Neutropaenic
Severe and refractory septic shock

Eg. IV Fluconazole

Question 11

Meningococcaemia: Management

Answer 11

Neisseria Meningitidus
Gram neg diplococci
___________

Isolate + droplet precautions

Support for:
- Shock
- Cerebral oedema
- MODS
- Skin and limb necrosis (eg. fasciot)

DOUBLE CEFTRIAXONE 100mg/kg (4g)

Notifiable disease
Consider PEP for contacts

Question 12

What does the meningococcal vaccine cover?

Answer 12

Quadrivalent: A, C, W, Y
Then Men B given separately.