E.Coli Sepsis

Question 1

You are asked to review a patient on the ward who was admitted 48 hours prior with features of sepsis, and a provisional diagnosis of bronchitis. His blood cultures have returned today with 4/4 bottles growing E.Coli. How would you assess and manage this?

Answer 1

Impression
E Coli sepsis given growth on cultures. This is unlikely to have occurred secondary to bronchitis as this is an extremely rare pathogenic cause, therefore I am considering other sources of this infection and potential complications including;

GI tract causes

• UTI/Pyelonephritis
• Perforated viscus/PUD
• Biliary tract pathology (cholecystitis, cholangitis)
• Diverticulitis

Want to consider whether immunocompromised, recent procedures, other risk factors for current presentation.

Goals

• Review patient, taking A to E approach to assess for compromise and HD instability
• Review treatment, adjust based on sensitivity results from MCS and liaise with ID and treating team (switch from empirical to targeted ABx therapy)

Question 2

E.Coli sepsis (gram negative sepsis) - Assessment

Answer 2

Assessment
Assess for ongoing treatment plan, assess IV fluids, ABx, etc, liaise with senior colleagues re culture results and subsequent ABx treatment
- E Coli sepsis can cause rapid septic shock mediated by Lipid A moiety (endotoxin)
- Ensure HD stability before continuing with assessment and management.

A to E with focus on Circulation
A
B
C - IV access if not already. initial bloods (VBG), FBC, UEC. HR/BP monitoring. Cardio exam for signs of shock (cap refill, peripherally warm, reduced JVP, urine output, etc). Hydration status and ensure appropriate fluids/resus- consider bolusing if hypotensive.
DEFG as per normal

Question 3

E. coli sepsis - History

Answer 3

History

• PC: fluid intake,
• sx: fevers, onset, duration, progression
• resp: cough, production, duration/timing, wheeze, tightness, SOB, dyspnoea
• shock: lethargy, LOC/dizziness, altered mental state
• HPI: aspiration? recent hospital stays
• PMHx: immunocompromised, recent bowel/llung procedures, recent ABx use, and other recent illnesses (UTI, etc), medications (chemotherapy), allergies
• SNAP

Question 4

E. coli sepsis - Examination

Answer 4

Examination

• Review vitals, check obs since admission for trends
• General appearance from end of bed, look toxic?
• cardioresp exam: cap refill, wheeze, crackles, consolidation, reduced air entry,
• Abdo examination: localised tenderness, peritonitis, renal angle tenderness, epigastric, Murphy’s sign, etc
• Assess lines/catheters for evidence of infection
• Fluid status examination

Question 5

E. coli sepsis - Investigations

Answer 5

Investigations
- review existing investigation results and trends + cultures, particularly ABx sensitivities.

Bedside: UA, Urine MCS, VBG (lactate), ECG, sputum MCS for ?bronchitis source
Bloods: FBC, UEC, LFT, CRP/ESR, Coags (DIC)
Imaging: based on Hx/Ex findings: CXR, CT chest Abdo US for ?pathology, CT abdo

Question 6

E.Coli sepsis - Management

Answer 6

Management
Supportive
- discuss with senior colleagues + input from ID, etc
- fluid maintenance
- analgesia
- antipyretics
- regular obs
- VTE prophylaxis, adequate nutrition, ulcer prophylaxis

Definitive
- Switch from empirical to targeted ABx therapy
For E.Coli
o Ceftriaxone/Cefotaxime or Amp/Augmentin usually +/- Gent STAT
o Refer to local guidelines
o 5-7 day duration of treatment
- Consult for Bronchitis, initiate specific management