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Therapeutics > BACTEREMIA AND SEPSIS > Flashcards

BACTEREMIA AND SEPSIS Flashcards

1
Q

Symptoms that may reflect metastatic staph. aureus bacteremia

A
  1. bone or joint pain (septic arthritis)
  2. protracted fever, night sweats, murmur, heart failure (endocarditis)
  3. abdominal pain, especially LUQ pain (splenic infarction)
  4. CVA tenderness (renal infarct or PSOAS abscess)
  5. HA, difficulty breathing, altered mental status (septic emboli)
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2
Q

Clinical approach to SAB

A
  1. physical exam - metastatic seeding may occur within the first few days of hospitalization but may not be clinically apparent for several weeks
  2. infectious disease consult - decreased mortality, fewer relapses, and decreased readmission rates
  3. repeat blood cultures q48-72h to document clearance - treatment day starts day of negative blood cultures
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3
Q

Echocardiography

A
  • TTE performed first in SAB -identifying vegetation size/location
  • TEE usually performed after TTE (preferred for MRSA bacteremia) - identifying intracardiac abscesses and valve perforation
  • most sensitive when performed 5-7 days after onset
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4
Q

staphylococcus aureus in urine

A
  • not common organism in UTIs

- translocation of S. aureus from blood to urine due to hematogenous seeding and development of micro-abscesses

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5
Q

Catheter and prosthetic device management in SAB

A

-attempt to remove all prosthetic devices; if not, significant increase in risk of relapse
-if unable to remove may add rifampin and may need long-term suppressive therapy
short term catheters- remove asap
long term catheters- remove unless major CI
replace catheters when blood cultures are negative for 48-72 hrs

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6
Q

Empiric treatment of SAB

A
  1. prompt source control

2. empirically cover MSSA and MRSA: vancomycin or daptomycin

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7
Q

Treatment of MSSA bacteremia

A

nafcillin, oxacillin, cefazolin

-DO NOT USE: vanocmycin, combination with rifampin, combination with aminoglycosides unless endocarditiis

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8
Q

Treatment of MRSA bacteremia

A

Vancomycin or Daptomycin

  • dapto can be used in patients with septic pulmonary emboli because the clot is inside the vasculature and there is no surfactant present
  • addition of gentamicin or rifampin to vancomycin is not reccomended unless infective endocarditis with prosthetic heart valve
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9
Q

Combination therapy for MRSA bacteremia

A

it may be reasonable to employ combination therapy with a PBP-1 active beta-lactam or ceftaroline with vanco or dapto early in MRSA bacteremia especially in patients at the highest risk of treatment failure and death

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10
Q

Duration of treatment for SAB

A
  • uncomplicated SAB 14 days of IV therapy from the first negative blood culture.
  • complicated SAB 4-6 weeks
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11
Q

criteria for uncomplicated SAB

A
  • exclusion of endocarditis (negative TTE, TEE)
  • no indwelling or implantable devices or prostheses
  • follow-up blood cultures drawn 2-4 days after initiating IV therapy and removal of the presumed focus on infection are negative
  • patient defervesced with 48-72 hours after initiating IV therapy and removal of the presumed focus on infection
  • no evidence of metastatic infection
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12
Q

Systemic inflammatory response syndrome (SIRS)

A
  • systemic inflammatory response to a variety of severe clinical insults (infectious or non-infectious), manifested by 2 or more of the following conditions:
    1. temperature >100.4 (38C) or <96.8 (36C)
    2. HR > 90 BPM
    3. RR >20 BPM or PaCO2 <32 mmHg
    4. WBC >12000/mm3, <4000/mm3, or >10% immature (band) forms
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13
Q

Septic shock

A
  • subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with higher risk of mortality than sepsis alone
  • patients requiring vasopressors to maintain a MAP 65 mmHg and serum lactate >2 mmol/L (>18 mg/dL) in the absence of hypovolemia
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14
Q

Causative pathogens in sepsis and septic shock: gram (-)

A
  1. enterobacteriacea (E. Coli, Klebsiella, Enterobacter, Serratia, Proteus)
  2. enteric gram (-) bacteria - normal endogenous flora within the GI tract
  3. integrity of the GI mucosa - mechanical barrier (trauma, penetrating wounds, ulcerations, mechanical obstruction, ischemia)
  4. pseudomonas- mechanical ventilation, prolonged hospitalization, burn injury
  5. acinetobacter (prior antibiotic exposure)
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15
Q

Causative pathogen in sepsis and septic shock: gram (+)

A
  1. staphylococci- associated with intravascular devices, artificial heart valves
  2. S. pneumonia
  3. enterococci - prolonged hospitalization treatment with cephalosporins
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16
Q

Causative pathogen in sepsis and septic shock: fungi

A
  1. C. albicans

2. C. glabrata, C. parapsilosis, C. trropicalis, C. krusei

17
Q

Procalcitonin in sepsis

A

Initiating antibiotic therapy
1. <0.25 ng/mL - antibiotics strongly discouraged
2. >0.25 and <0.5 ng/mL - antibiotics discouraged
3. >/= 0.5 and <1 ng/mL - antibiotics encouraged
>1 ng/mL - antibiotics strongly encouraged

Continuing or stopping antibiotic therapy

  1. <0.25 ng/mL - stopping antibiotics strongly encouraged
  2. > 0.25 and <0.5 ng/mL - stopping antibiotics encouraged
  3. > 0.5 ng/mL - continuing antibiotics encouraged
  4. > 0.5 ng/mL - changing antibiotics strongly encouraged
18
Q

Laboratory/diagnostic in sepsis and septic shock

A
  1. blood cultures -at least 2 sets (aerobic and anaerobic)
  2. specimens for direct examination and culture from any primary or metastatic site of infection
  3. obtain before antimicrobial therapy if no significant delay
  4. WBC with differential
  5. coagulation tests
  6. SCr, BUN, LFTs to determine organ dysfunction
  7. imaging studies
19
Q

To be completed in the first 3 hours of presentation of sepsis/septic shock

A
  1. measure lactate conc
  2. obtain blood cultures prior to administration of antibiotics
  3. administer broad-spectrum antibiotics
  4. administer 30 mL/kg of crystalloid (NS or LR) for sepsis-induced hypotension or septic shock, or lactate >4 mmol/L
20
Q

To be completed in the first 6 hours of presentation of sepsis/septic shock

A
  1. apply vasopressors (for hypotension not responding to fluid resuscitation) to maintain MAP > 65 mmHg - norepinephrine is the first line
    - if MAP is not at goal add vasopressin
    - if MAP not at goal with levo + vaso add epinephrine
21
Q

MAP calcualtion

A

MAP = systolic + 2 x diastolic / 3

22
Q

Empiric therapy for sepsis in adults with community-acquired infection in non-neutropenic patients (ANC > 1000/mm3): pneumonia

A
  1. ceftriaxone + azithromycin

2. ceftriaxone + respiratory FQ (Moxi or Levo)

23
Q

Empiric therapy for sepsis in adults with community-acquired infection in non-neutropenic patients (ANC > 1000/mm3): UTI

A
  1. 3rd or 4th gen cephalosporin (+/- aminoglycoside)
  2. zosyn (+/- aminoglycoside)
  3. FQ (cipro or levo)
24
Q

Empiric therapy for sepsis in adults with community-acquired infection in non-neutropenic patients (ANC > 1000/mm3): suspected intra-abdominal source

A
  1. zosyn
  2. carbapenem
  3. 3rd or 4th gen cephalosporin + metronidazole
  4. cipro or levo + metronidazole
25
Q

Empiric therapy for sepsis in adults with community-acquired infection in non-neutropenic patients (ANC > 1000/mm3): SSTI (cellulitis)

A
  1. vancomycin
  2. linezolid
  3. daptomycin
26
Q

Empiric therapy for sepsis in adults with hospital-acquired infection in non-neutropenic patients (ANC > 1000/mm3): HAP/VAP

A

anti-pseudomonal beta-lactam + aminoglycoside or antipseudomonal FQ + vancomycin or linezolid

27
Q

Empiric therapy for sepsis in adults with hospital-acquired infection in non-neutropenic patients (ANC > 1000/mm3): UTI

A
  1. cefepime + aminoglycoside (tobramycin) or FQ

2. zosyn + aminoglycoside (tobramycin) or FQ

28
Q

Empiric therapy for sepsis in adults with hospital-acquired infection in non-neutropenic patients (ANC > 1000/mm3): suspected intra-abdominal source

A
  1. zosyn

2. carbapenem (not ertapenem)

29
Q

Empiric therapy for sepsis in adults with hospital-acquired infection in non-neutropenic patients (ANC > 1000/mm3): SSTI (cellulitis, necrotizing fasciitis)

A

vancomycin + zosyn (+ clindamycin if necrotizing fasciitis)

30
Q

empiric treatment of a hospital-acquired sepsis infection (neutropenic patient)

A
  1. zosyn +/- aminoglycoside
  2. antipseudomonal carbapenem (not erta) +/- aminoglycoside
  3. ceftazidime or cefepome +/- aminoglycoside
31
Q

empiric treatment for sepsis infection with thermal injury to at least 20% of body SA

A

antipsuedomonal beta-lactam + aminoglycoside + vancomycin

32
Q

Empiric treatment for sepsis infection with suspicion of indwelling vascular catheter infection

A

vancomycin, daptomycin, linezolid

33
Q

duration of empiric therapy

A

7-10 days

34
Q

Vasopressors in sepsis/septic shock

A
  1. target MAP of 65 mmHg
  2. Norepinephrine is the first choice.
  3. vasopressin can be added to NE to either increase MAP or decrease NE dose
  4. Epinephrine may be added to NE and vaso if needed to maintain adequate blood pressure
  5. dopamine alternative vasopressor only in highly selected patients (patients with low risk of tachyarrhythmias and bradycardia)
  6. phenylephrine only in circumstances where NE is associated with serious arrhythmias, CO is known to be high and BP is persistently low, salvage therapy
35
Q

Inotropic therapy in sepsis/septic shock

A

dobutamine infusion may be administered or added to vasopressors in the presence of myocardial dysfunction or ongoing signs of hypoperfusion

36
Q

Corticosteroids in sepsis/septic shock

A

IV hydrocortisone for septic shock that remains poorly responsive to fluid resuscitation and vasopressors - do not administer in absence of shock

Therapeutics (11 decks)

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