Sepsis Flashcards
Risk factors for sepsis
Obesity
Impaired glucose tolerance / diabetes
Impaired immunity/ immunosuppressant medication
Anaemia
Vaginal discharge
History of pelvic infection
History of group B streptococcal infection
Amniocentesis and other invasive procedures
Cervical cerclage
Prolonged spontaneous rupture of membranes
GAS infection in close contacts / family members
Of black or other minority ethnic group origin
Indications for transfer to ICU?
Cardiovascular:
Hypotension or raised serum lactate persisting despite fluid resuscitation, suggesting the need for
inotrope support
Respiratory:
Pulmonary oedema
Mechanical ventilation
Airway protection
Renal:
Renal dialysis
Neurological:
Significantly decreased conscious level
Miscellaneous:
Multi-organ failure
Uncorrected acidosis
Hypothermia
Most common organisms?
Streptococcus and E coli
Profile of the following antibiotics and their limitations:
Cefuroxime
Class: cephalosporin
Coverage: Gram +ve/-ve
MOA: Inhibit cell wall synthesis
Limitations: association with C. difficile. Doesn’t provide any MSRA, Pseudomonas or ESBL cover
Pregnancy: Safe
Profile of the following antibiotics and their limitations:
Augmentin
Class: penicillin with addition of clavulanic acid
Coverage: Gram +ve/-ve
MOA: Inhibit cell wall synthesis (bactericidal)
Limitations: Does not cover MRSA or Pseudomonas
Pregnancy: Possible association in 1st trimester with cleft palate, in 3rd trimester concern about increased risk of NEC in preterm babies
Profile of the following antibiotics and their limitations:
Metronidazole
Only covers anaerobes
Safe in pregnancy although cochrane review found increased risk of adverse outcomes when used in the first trimester to treat BV/trich
Profile of the following antibiotics and their limitations:
Tazocin and carbapenems
Piperacillin–tazobactam Covers all except MRSA and are renal sparing (in contrast to aminoglycosides).
(Tazocin) and carbapenems
Profile of the following antibiotics and their limitations:
Gentamicin
Class: aminoglycoside
Coverage: Gram -ve
MOA: Inhibit protein synthesis
Limitations: nephrotoxic if AKI/CKD, serial doses need serum levels monitoring
Pregnancy: Safe
Profile of the following antibiotics and their limitations:
Clindamycin
Class: Lincosamide
Coverage: Gram +ve and anaerobes
MOA: Inhibit protein synthesis (bacteriostatic)
Covers most streptococci and staphylococci, including many MRSA, and switches off exotoxin production
with significantly decreased mortality. Not renally excreted or nephrotoxic.
Pregnancy: Safe
Limitations: associated with colitis and C diff.
Profile of the following antibiotics and their limitations:
Doxycycline
Class: tetracycline
Coverage: Gram +ve/-ve
MOA: Inhibit protein synthesis (bacteriostatic)
Pregnancy: Causes staining and dental hypoplasia therefore should not be given to pregnant women. Very limited course if no suitable alternative if breastfeeding
Profile of the following antibiotics and their limitations:
Co-trimoxazole
Sulfamethoxazole and trimethoprim
Class: Sulfamethoxazole- sulfonamide
Trimethoprim- folate antagonist
Coverage: Gram +ve/-ve
MOA: Folate antagonist- therefore affects bacterial DNA synthesis
Pregnancy: TP: avoid in the first trimester as antifolate
Sulfonamides should be avoided in the 3rd trimester due to risk of kernicterus in newborn
Profile of the following antibiotics and their limitations:
Erythromycin
Class: macrolide
Coverage: Gram +ve
MOA: Inhibit protein synthesis
May also have some anti-inflammatory effects
Pregnancy: Safe
Other drugs within macrolide class:
- Azithromycin- lower serum concentration but higher tissue. Better gram negative cover. Can be used for chlamydia. Has a long half life.
- Clarithromycin- greater activity than erythromycin with higher tissue levels
Another drug that can be used for severe strep/staph sepsis requiring intensive care?
IVIG
IVIG has an immunomodulatory effect, and in staphylococcal and streptococcal sepsis it also
neutralises the superantigen effect of exotoxins, and inhibits production of tumour necrosis factor
(TNF) and interleukins
Risks to the fetus of maternal sepsis
- Increased risk of neonatal encephalopathy and cerebral palsy
- Preterm delivery
When to consider delivery?
Attempting delivery in the setting of maternal instability increases the maternal and fetal mortality rates unless the source of infection is intrauterine.
The decision on mode of delivery should be individualised by the consultant obstetrician with consideration of severity of maternal illness, duration of labour, gestational age and viability
Definition of sepsis
life-threatening organ dysfunction caused by
a dysregulated host response to infection
What scoring system is recommended by SOMANZ?
omqSOFA score
SOFA score: Sequential (sepsis-related) Organ Failure Assessment score (SOFA) has been shown to be useful in identifying those patients with a suspected
infection who are likely to have a prolonged ICU stay or die in hospital.
q- quick
om- obstetrically modified
omq-SOFA score?
- systolic blood pressure of 90 mmHg or less
- respiratory rate of 25/min or greater
- altered mentation (any state other than ‘Alert’ on maternal observation charts).
om-SOFA score?
Looking at end organ dysfunction in the following groups:
- Respiration: parameters related to hypoxia
- Coagulation: low platelets
- Liver: Raised bilirubin
- Cardiovascular: hypotension
- Central nervous system: reduced AVPU score
- Renal: evidence of AKI
Definition of septic shock
- Vasopressors required so maintain systolic BP
- Lactate >2 despite adequate fluid resuscitation
Effects of maternal fever in early pregnancy?
Association with NTD, oral clefts
Weak association with congenital heart defects
Association with ASD and developmental delay- particularly if antipyretics weren’t used
No effect of maternal fever was seen on the risk
of miscarriage, stillbirth or preterm labour
Non-infectious conditions that can mimic sepsis in pregnancy
PE AFE Pancreatitis Acute fatty liver of pregnancy Adverse drug reactions, Acute liver failure Acute adrenal insufficiency Acute pituitary insufficiency Autoimmune conditions Concealed haemorrhage Disseminated malignancy Pelvic thrombosis Transfusion reactions
First line management?
Within 1 hour: Sepsis 6+2:
- Blood cx and cx other potential sources e.g. urine
- Serum lactate and bloods
- Strict measurement of fluid balance
- Antibiotics
- IVF
- O2 to maintain sats >94%
- Assess fetal state and consider delivery/evac of RPOC
- Consider thromboprophylaxis
In severe sepsis how much can mortality be increased by each hour of delay in antibiotics?
8%
SOMANZ antibiotic recommendations for sepsis of unknown origin?
Community:
- Oz: amox + gent + metronidazole
- NZ: cef + met + gent
Hospital:
- Oz: taz + gent + metronidazole
- NZ: same
If at risk of GAS: add in clindamycin 600mg IV
If at risk of MDR organism: add in meropenem
Treatment of flu in women that are systemically unwell?
Use of Oseltamavir within 48 hours of presentation reduced ICU admissions by 84%
Anaesthesia in the context of maternal infection?
Avoid spinal/epidural as risk of infectious complication is increased
Definition of chorioamnionitis?
Acute inflammation of the membranes and chorion of the placenta
More common when membranes ruptured. Can occur without- then more commonly due to ureaplasma/mycoplasma. Haematogenous spread from listeria.
Risk factors for chorio?
Longer duration of membrane rupture, prolonged labor, nulliparity, internal monitoring of labor, multiple vaginal exams, meconium-stained amniotic fluid, smoking, alcohol or drug abuse, immune-compromised states, epidural anaesthesia, colonization with GBS, bacterial vaginosis, sexually transmissible genital infections vaginal colonization with ureaplasma
Diagnosis of chorio?
Clinical features: fever, uterine fundal tenderness, maternal or fetal tachycardia and purulent or foul amniotic fluid
Histopathological features
Microbiologic - ie swabs confirming infection
Pathogenesis of chorio?
- passage of infectious organisms to the chorioamnion and/or umbilical cord of the placenta
- Either ascending, haematogenous, via fallopian tubes, or from procedure e.g. amnio
- Maternal and fetal inflammatory response
- Fetal response may affect cerebral white matter and therefore increase risk of cerebral palsy
- The inflammatory response may produce clinical chorioamnionitis and/or lead to prostaglandin release, ripening of the cervix, membrane injury and labour at term or premature birth at earlier gestational ages
Maternal complications of chorioamnionitis?
Increased risk of:
- CS
- Postpartum endometritis/abscess
- PPH (due to inefficient uterine contraction from inflammation)
- Severe sepsis
Fetal/neonatal complications of chorioamnionitis?
Preterm birth Perinatal death Cerebral palsy/developmental delay Neonatal sepsis IVH
