Critical Care: ABX and Glucocorticoids in Sepsis

Question 1

List two principal considerations when selecting empiric antibiotics in sepsis

Answer 1

1. suspected location of infection

2. risk of multidrug-resistant pathogens

Question 2

List four common sources of infection in sepsis

Answer 2

1. lung
2. abdomen
3. blood
4. urinary tract

Question 3

List four risk factors that should be weighed when considering empiric fungal therapy for sepsis

Answer 3

1. recent abdominal surgery
2. long-term PN
3. indwelling central venous catheters
4. recent treatment with broad-spectrum antibiotics
5. immunocompromised

Question 4

List five immunocompromising conditions to consider in sepsis

Answer 4

1. chronic corticosteroids
2. immunosuppressants
3. neutropenia
4. malignancy
5. organ transplant

Question 5

List three options for empiric fungal therapy in sepsis

Answer 5

1. triazoles, such as fluconazole
2. echinocandin
3. lipid formulation of amphotericin B

Question 6

List three compelling indications for using echinocandins as the antifungal in sepsis

Answer 6

1. septic shock
2. recently treated with antifungal agents
3. candida glabrata or candida krusei

Question 7

List four additional considerations in select of empiric antimicrobial therapy

Answer 7

1. history of drug allergy or intolerance
2. recent antibiotic use
3. comorbidities
4. antimicrobial susceptibility patterns

Question 8

Consider empiric antiviral therapy with ________ for patients presenting with ________

Answer 8

1. oseltamivir

2. Patients presenting with flulike symptoms during flu season

Question 9

Describe the timing of antimicrobials in relation to other procedures in the bundle

Answer 9

1. begin IV antimicrobials as soon as possible, at least within first hour
2. ideally after two sets of blood cultures and other potential sites of infection

Question 10

If several antibiotics are prescribed, then _______

Answer 10

administer the broadest coverage first and infuse as quickly as possible

Question 11

Mortality increases by ___% for each 1-hour delay in administering appropriate antimicrobials

Answer 11

7.6%

Question 12

Appropriate antimicrobials do not reduce the importance of emergency source control by these three things:

Answer 12

1. drainage
2. debridement
3. device removal

Question 13

List two factors when considering antimicrobial de-escalation

Answer 13

Culture data or clinical judgment

Question 14

Empiric use of combination therapy should not be administered for longer than ____ days if de-escalation to a single agent is appropriate

Answer 14

3-5 days

Question 15

Consider discontinuing antimicrobials after ____ days for most serious infections

Answer 15

7-10 days

Question 16

List five factors that may require a longer duration of ABX for sepsis than what is standard

Answer 16

1. slow response
2. an undrainable foci
3. immunologic deficiences
4. bacteremia with S. aureus
5. Some fungal or viral infections

Question 17

____, a serum biomarker, can be used as a guide for antibiotic therapy

Answer 17

Procalcitonin

Question 18

Describe the pros and cons of protocols that encourage or discourage the use of ABX based on certain serum biomarkers concentrations

Answer 18

(procalcitonin)

1. Decrease unnecessary antibiotic use
2. Without increasing harm to patients

Question 19

_____ antimicrobials if no infectious cause if found

Answer 19

discontinue

Question 20

What is the underlying biological plausibility for using corticosteroids in sepsis?

Answer 20

Adrenal function in critically ill patients can be suppressed by endotoxins produced by bacteria AND by the body’s immune response to stress

Question 21

Describe relationship between vasopressosr and glucocorticoids in sepsis

Answer 21

Early studies showed a relationship between vasopressor responsiveness and glucocorticoid administration

Question 22

How can you test a patient’s corticotropin response in sepsis? Is it recommended?

Answer 22

1. No longer recommended

2. A corticotropin stimulation test “stim test”

Question 23

Describe how a corticotropin stimulation test is performed

Answer 23

Administering 250 mcg of cosyntropin (synthetic adrenocorticotropic hormone) and measuring cortisol concentrations at baseline, 30 minutes and 60 minutes after

Question 24

How to interpret a corticotropin stimulation test?

Answer 24

1. A cortisol increase of 9 mcg/dL is said to be an appropriate response. (i.e. responders)
2. Changes of less than 9 mcg/dL may indicate corticosteroid insufficiency

Question 25

Describe three reasons why corticotropin stimulation tests are not recommended in the general ICU population

Answer 25

1. High dose of cosyntropin administered
2. Inability to measure free (active) cortisol
3. Lack of data on outcomes on responders vs. nonresponders

Question 26

Describe the SSC guidelines on use of corticosteroids in sepsis

Answer 26

1. SSC recommends against using hydrocortisone to treat adults with septic shock if adequate fluid resuscitation and vasopressor therapy are able to erstore hemodynamic stability
2. If this is not achievable, the SSC suggests intravenous hydrocortisone alone at a dose of 200 mg per day.

Question 27

What do the American College of Critical Care Medicine corticosteroid insufficiency guidelines recommend?

Answer 27

1. Hydrocortisone should be considered in the management for patients with septic shock, particular those who have responded poorly to fluid resuscitation and vasopressor therapy.

Question 28

What do the SSC guidelines about about fludrocortisone?

Answer 28

Although fludrocortisone was a component of the treatment regimen in some studies, the SSC only includes hydrocortisone in recommendations for septic shock

Question 29

What do the American College of Critical Care Medicine say about discontinuing corticosteroid therapy?

Answer 29

Patients should be weaned off of steroid therapy once vasopressors are no longer necessary

Question 30

What do the different guidelines say about the role of corticotropin stimulation test in identifying subset of patients for corticosteroid treatment?

Answer 30

1. SSC recommends against using the corticotropin stimulation test to identify the subset of adults with septic shock who should receive hydrocortisone.
2. ACCM says stim test shoudl not be used to identify patients with septic shock or acute respiratory distress syndrome (ARDS) who should receive glucocorticoids.

Question 31

List four landmark trials in the use of steroids in septic shock

Answer 31

1. A study in 2002
2. CORTICUS (2008)
3. ADRENAL (2018)
4. APROCCHSS (2018)

Question 32

Describe the study in 2002 published about adult patients with septic shock and corticosteroids

Answer 32

1. Population: Adult patients with septic shock
2. Intervention: IV hydrocortisone + oral fludrocortisone
3. Comparison: placebo
4. Outcome: Steroid therapy improved 28-day survival, which was driven by the improvement by nonresponders. Responders to the stim test showed no improvement with steroids.

Question 33

Describe CORTICUS (2008)

Answer 33

1. Population: Adult patients with septic shock
2. Intervention: IV hydrocortisone
3. Comparison: Placebo
4. Outcome: Corticosteroids not associated with mortality benefit. Associated with higher risk of hyperglycemia, new sepsis or septic shock.
5. Implication: Corticosteroids are not recommended in patients with septic shock who have been stabilized with fluid and vasopressor therapy.

Question 34

Describe ADRENAL (2018)

Answer 34

1. Population: Adult patients with septic shock
2. Intervention: IV hydrocortisone
3. Comparison: Placebo
4. Outcome: No difference in 90-day all cause mortality, but hydrocortisone had decreased duration of septic shock and blood transfusions.
5. This is the largest randomized controlled trial assessing steroids in septic shock.

Question 35

Describe APROCCHSS (2018)

Answer 35

1. Population: adult patients with septic shock
2. Intervention: IV hydrocortisone + oral fludrocortisone
3. Comparison: Placebo
4. Outcome: Decrease in 90-day all cause mortality and duration of septic shock in patients treated with hydrocortisone and fludrocortisone

Question 36

Describe the current controversies with glucocorticoids in septic shock

Answer 36

1. There seems to be consistency as to the short-term benefits including decreased time to resolution of shock.
2. The mixed results from numerous studies leaves uncertainty as to the mortality benefit of steroid in septic shock.