Infections - clinical management of sepsis Flashcards
§What is sepsis?
body response to an infection injures its own tissues and organs
What is the difference between sepsis and septic shock?
septic shock = is a subset of sepsis, circulatory, cellular and metabolic abnormalities and increases risk of mortality
How many people is affected by sepsis annually?
141,722 cases (2014-15)
increases 11.5%
Why is there an increase in sepsis in population?
- aging population (older, more likely to develop sepsis)
- people living with co-morbidities
- immuno-suppriessive drugs
- ^ in antimicrobial resistance
What causes sepsis?
exact - unknown
1) patient factors
2) pathogen factors
3) enviromental factors
1) patient factors - cause
genetics, age and co-morbidities
2) pathogen factors - causes
type of pathogen, virulence, burden
3) enviromental factors - causes
anti-microbial resistance (differ from country to country)
Coagulation and immune responses are switched on by infection, what does this cause?
Dysfunction to one or more organs with variable severity»_space; multiple organ failure
What are the signs & symptoms of sepsis?
- sweaty skin
- disorientation
- shivering
- high HR
- extreme pain or discomfort
- short of breath
symptoms of sepsis - continued
signs of dehydration; reduced output in past 18hrs, dry mucosal membranes
altered behaviour / mental state (confusion, irritability- children)
sudden changes in functional ability - walking, balance, unable to dress
SYMPTOMS - acronym
SEPSIS
S = slurred speech or confusion
E = extreme shivering or muscle pain
P = passing no urine (in a day)
S = severe breathlessness
I = “i feel like im going to die”
S = Skin mottled or discoloured
Whos is at risk of sepsis
Adults over 65 years
Children younger than 1
Sepsis survivors
People with severe illness resulting in hospitalization
Prople with chronic conditions
People with weakened immune system
What are the risk factors or sepsis?
age
recent surgery ( within last 6 weeks / biopsy)
Breaches in skin integrity (cuts/ burns/ blisters/ skin infec.)
Misuse of IV drugs
Pregnancy (given birth in last 6 weeks, if c-section, miscarried or termination in last 6 weeks)
Pateinst with an impared immune function - treated fir cnacer with chemotherapy, impared immune system e.g. diabetes, p taking long term steroids, patients on immunosuppressant drugs e.g. biologics used to tread iBD/RA)
How to diagnose Sepsis (can be challenging - nonspecific symptoms)
- misconception - high temp, can be low
NEED thorough history;
SYMPTOMS ; deteriation
- conceers from relatives > appearance/ behaviour
RISK OF SEPSIS
>1 risk factor
OTHER
risk of antibimrobial resistance
immunisation status - all childhood vaccinations?
What to include when doing a thorough patient assessment?
examine patients
full examination - possible source of infec.
- capillary refill time (slow = poor peripheral perfusion)
- cold peripheries
- skin; mottled/ ashen skin, cyanosis
- rashes?
- signs of dehydration
Cognitive assessment - brain tests (check confusion)
Observtions
- temp - fever
- HR - tend to be elevated
- Resp rate - distress? high or low RR
- BP: 40% septic patients hypotension
What diagnostic tests must be done when diagnosing sepsis?
Chest X - ray
CT scan
Urine sample
Sputum sample
Faeces sample
Wound swab
Blood cultures
Blood - U&Es (kidney function), lactate (tend to be ^^) CRP (tend to be ^^) , FBC, glucose
Arterial blood gases ABG) - says o2 saturation
Complication of sepsis?
- Death
5 patients per hr in Uk, 20% will die, sepsis claim more lives than lung, bowel, prostate and breast cancer combined) - Organ failure
an infection triggers response - body attack itself - Coagulopathy
DIC - start to from microemoli, get stuck in periphery, but all of platelet have been used to form clots in body»_space; loss of fingers, toes, and loss of limbs - Permanent life changing affects
PTSD, chronic pain and fatigue, ^ risk of infec. amd SEPSIS again in future
Memory loss
Suspect sepsis if….
- Urine infec - but deteriate rapidly
- one or more risk factors
- Relative concers of p behaviour and appearence
- Red flags - deteriation
Red flags for sepsis:
- new onset confusion
- systonic is <90mmHg (drop of >40mmHg from normal)
- HR >130bpm
- resp rate >25 bpm
- needs oxygen therapy to maintain o@ sats > 92% (88% COPD)
- skin sumptoms
non-blanching rash, mottled, asehn, cyanosis (lips/tongue) - Lactate >2mmol/L
- recent chemo
- Not passing urine in the last 18hrs
SEPSIS SIX, what is it?
Should be done in the first hour!
1. give high flow oxygen
2. take blood cultures - BEFORE starting Abx)
3. Give IV antibiotics (pharmacists, correct drug and dose)
4. GIVE IV fluids
5. Measure lactate
6. Measure urine output
antibiotic choice - ‘smart smart then focus’
- broad spectrum anti-biotics > cover potential causative agents
Antimicrobial revoew - 48-72 hrs of starting inition IV antibiotic
rarely only one antimicrobial used > often a combo of antibiotics
in ALL WALES drug chart
antibiotic review is in built
if e-drug chart
if antibiotic is prescirbed = suspended within 72hrs to be reviewed by doctor
antibiotic review:
- following 48-72 hrs > reviewed by SENIOR CLINICAN
- decision need to be made regarding antimicrobial management
- Abx to stop? - infection rules out
- IV to ORAL switch > if p well enough
Infection marker showing a trend towards normal; temp, BP stable, CRP - marker for inflammation usually lag in 24-48 hrs, pulse <90
, resp rate <20, WCC between 4-12
antibiotic CHOICE:
- antibiotic vary from health board to “
anti microb. resistance, circulating causative agent, local antibiotic guidlines
consider; source of infec (chest, urine, abdominal)
Patient charicteristics - allergies/ renal and hepatic func./ interacting medication
Risk of anti mircob resistance > p been given any antibiotics recently
immunisation status
local/ national antimicrobial guile-lines > anti microbial stewarship - funamental role of pharmacist.
What antibiotic regimen?
unkown source
chest source
abdominal source
urine source
Sepsis on unknown source;
Renal func >20mls/min
No penicillin allergy
Drug & route - amoxicillin (IV) 1g TDS / Gentamycin (IV) 5mg/kg OD - dose banded
Consider adding; Clarythromycin (IV) 500mg BD / Metronidazole (IV) 500mg OD - dose banded
Penicillin allergy?
Levofloxacin (IV/PO) 500mg BD
Gentamycin (IV) 5mg/kg OD - dose banded
Consider addinng;
Metronidazole (IV) 500mg TDS
No penicillin allergy but renal func/ <20mls/mis
Tazocin (IV) 4.5mg (as CrCL <20ml/min)
Clarythromycin (IV) 500mg BD
Gentamycin
durg class - aminoglycoside
acterial cover - Gram -ive bacilli
Dose - 5mg/kg OD
Route - IV - not absorbed through gut
S.e - otoxicity - deafness
nephrotoxicity - renal failure
contraindications - blindness, renal impairmetn (<20ml/min), myasthenia gravis, allergy ti amunoglycoside
Monitoring - NARROW therapeutic index drug > small changes in dose or clearnec of drug >»_space; change in therapeutic effect and drug levels
clearer by kidney
MUST monitor
drug levels
Monitoring renal function (GENTAMYCIN)
Cock-croft and gault equation
Monitor BEFORE using equation
monitor x2 weekly whilst on this drug if CrCL stable
deterioration in CrCL - daily monitoring maybe indicated
Cock-croft and gault equation:
estimated creatinine clearance (eCrCL) = (140-age) x weight (kg) / serum creatinine X 1.04 female or 1.23 male
what if patient obese ? ideal body weight can be used (IBW)
adjusted body weight (ABW) if patient is >120% of IBW
Therapeutic drug monitoring:
- narrow therapeutic drug
When? through level 18-24 hrs post dose, after first dose
range <1mg/L
How often? stable? (<1mg/L) twice weekly whilst on gentamycin
WHEN Level >1mg/L (chelc renal func., if worsening <20-30ml/min > alternative Abx needs to be prescribed
If level is high (> 1mg/L), hold drug for 12 hrs > retake the level 36 hrs post dose)
if still >1mg/L > hold for another 12 hrs and retake level (48hrs post op)
ADJUST DOSE
Councelling gentamycin
Risk of otoxicity and nephrotoxicity > VL risk of short courses
very effective antibiotic
bloods will be check to monitoring kindey function and level of antibiotics in blood
report any hearning problems e.g. ringing / noises in ear, dizziness or balance problems
Metronidazole
drug class - nitroimidazole
Bacterial cover - anaerobic bacteria and protoxoa
route - oral or IV
dose - 400mgTDS/ 500mg TDS
s.e - rare - peripheral neuropathy, pins and needles
central neuropathy - dizziness, convulsions
Blood dyscrasias (low PLT/ eosinophils)
Contra-indications - allergic reaction
monitor -
cleared by kideny
metobolised by liver
Counselling -
Topical ad: avoid sun light when using topically > wear sun cream
Oral/ Iv use
Avoid alcohol consumption whilst on metronidazole for at least 48 hrs after course
disulfiram- like reaction > flushing/ throbbing headachje / N&V
Vacomycin
drug class ; glycopeptide
bacterial cover; aeorbic gra +ive
anaerobic gram +ive - multi drug resistance staphycocci
dose: loading dose > determined by patient actual body weight
maintenance dose > determined by patients renal function (obese patients > IBW or AsBW)
route; IV\
s.e;
ototoxicity
nephrotoxocity> monitor kidney function closley
Infusion related reactions
allergic reactions
contra-indications; previous Hx of hearing loss
Monitoring;
narrow ther. index drug > small changes to drug >. large changes in ther. effects and drug levels
clearer by kidney
renal func + drug levels
administration; given slowly over hrs > red man syndrome (if developed, stop)
Vancomycin dosing
Initial loading dose ius based on thepatients actual body weight
vacomycin dosing - maintanence dose based on….
renal function
Vancomycin levels - monitor
what are normal?
10-15mg/L
- monitor x2 weekly
Sepsis - CHEST source
if <48 hrs since admission - community acquired pneumonia
> 48 hrs - hospital “
Sepsis - ABDOMINAL source
> 20 mls/min RENAL FUNC
No pen allergy:
amoxicillin (IV) 1g TDS
Gentamycin (IV) 5mg/kg OD
Metronidazole (IV) 500mg TDS
Pen allergic:
Gentamycin (IV) 5mg/kg OD
Metrodinazole (IV) 500mg TDS
Teicoplanin (IV) 6mg/kg
<20 mls/min RENAL FUNC.
No pen allergy;
tazocin (IV) 4.5g BD
Non-severe pen allergy
Meropenem (IV)
1g BD
Severe pen allergy
Teicoplanin (IV) 6mg/kg
Vancomycin (IV) - dep on CrCL
Caiplofloxacin (IV) - dep on CrcL
Teicoplanin
drug class - glycopeptide
Bacterial cover - aerobic gram +ive
anaerobic gram +ive
dose - loading dose > det on ABW
maint. dose > det by pateints weight & renal func.
route (IV)
s.e
blood dyscrasias
nephrtotoxicity > renal func monitor
allergic reaction
infusion related reaction
hearing loss
MONITOR
therapeutic druh levels (only if patient on period over 7 days)
Trough level, before 5th dose
target is 15-60mg/L
Blood count
teicoplanin dosing considering CrCL (mL/min)
30-80 > dose from table 1 every 48 hrs
<30 > give dose from tabel 1 every 72 hrs
sepsis - URINE source (urosepsis)
> 20 mls/lin renal func
Gentamycin (IV) 5mg/kg
(w or w/o penicillin allergy)
<20mls/min renal func.
no pen allerg.
Tazocin (IV) 4.5g BD
non-severe pen allerg.
Merepenem (IV) 1g BD
severe pen allerg. Ciprofolaxin (IV) - dep on CrCL
look at case study - wk 8
