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CLASP > Sepsis > Flashcards

Sepsis Flashcards

1
Q

Define colonisation

A

The presence of a microbe in the human body without an inflammatory response

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2
Q

Define bacteraemia

A

The presence of viable bacteria in the blood

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3
Q

Define sepsis

A

Life threatening organ dysfunction caused by dysregulated host response to infection

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4
Q

Define septic shock

A

Subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality

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5
Q

BP and Lactate paramters to define septic shock

A

Sepsis AND both of:

  • Persistent hypotension requiring vasopressors to maintain Mean Arterial Pressure (MAP) greater than or equal to 65 mm Hg, AND
  • Lactate greater than or equal to 2 mmol/l.

(despite adequate volume resuscitation)

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6
Q

What NEWS score likely means pt is resonding excessivey to infection?

A

5 or higher

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7
Q

Which people don’t repsond normally to infection?

A

Kids, elderly, pregnant, immunosuppressed, comorbid drugs, genetics, spinal cord injury
- use clinical judgement

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8
Q

When should you adjust up a pt’s NEWS score?

A

Clinical/carer concern

Deterioration
Surgically remediable sepsis (taking out abscess is better than antibios)
Neutropenia
Blood gas/ lab evidence organ dysfunction/lactate

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9
Q

Most common gm pos cocci source

A

Skin and soft tissues
Lines and devices

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10
Q

Most common gm neg bacilli source

A

Urinary
Gut
Biliary

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11
Q

Bug that is really sensitive to autolysis

A

Strep pneumoniae
- uses up all nutrients really quickly then population crashes and can’t detect bugs in culture bottles

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12
Q

Bugs v difficult to see on culture

A

Campylobacter
Legionella

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13
Q

Types of haemolysis

A

Alpha - incomplete
Beta - complete
Gamma - none

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14
Q

Why is it important to take cultures before giving antibios?

A

Much fewer pos cultures after antibios given

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15
Q

Where is CRP produced?

A

Liver
- normal range <10
- absent CRP due to hepatic failure e.g. does not mean low CRp

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16
Q

Why does PCT rise in infection?

A

Endotoxin and LPS produced by bacteria stimulates production of PCT which is excreted renally
- normal range ~0

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17
Q

High CRP and low PCT

A

Non-bacterial infection
Post surgical

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18
Q

Causes of gm neg sepsis

A

Escherichia coli,
- Klebsiella,Serratia, Acinetobacter, Enterobacter
Pseudomonas
Neisseria meningitidis
Neisseria gonorrhoea

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19
Q

Membrane of gm neg bacteria

A

cell envelope contains an additional outer membrane composed by phospholipids and lipopolysaccharides
- convey overall negatie charge
- pathogenicity is assoc with LPS layer

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20
Q

What are coliforms?

A

Pink rods existing as single bugs - no colony forming or clumping

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21
Q

What are ESBLs?

A

Extended Spectrum b-Lactamases
No response to penicillins, cephaosporins and aztreonam
Often have other resistance mutations and are spread via plasmid
- pts who get healthcare abroad often need rectal swab to determine if they have resistant bugs

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22
Q

Gentamicin protocol to minimise harm

A

Limit duration (72h then micro approvla)
Monitor renal function daily
Exclusion criteria
Nomogram when dose <1mg
Once only prescribing
Ref to ward pharmacist

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23
Q

Describe haemophilus influenzae

A

a gram-negative coccobacillus.
- aerobic but also facultative anaerobe
- grown on chocolate agar
- amoxicillin and doxycycline are active

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24
Q

Macrolides

A

-Mycin

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25
Q

Fluoroquinolones

A

-Floxacin

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26
Q

Managing atypical non-strep pneumonia

A

Doxycyline
(no kids or pregnant ppl)
Clarithromycin
Quinolones
(c diff risk)
Lower mortality than bacterial pneumonia, legionella is higher

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27
Q

How can legionella cause infection?

A

Live in lukewarm aerosolised water ( showers, air conditioning , taps)
Multiplies within amoebae and ciliated protozoa

Breathing in legionella causesinvasion and growth within alveolar macrophages

Pontiac fever is less severe disease

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28
Q

RFs for legionella infection

A

smokers, males, COPD, immunosuppressed, malignancy, diabetes, dialysis, hot tubs

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29
Q

Test to determine which type of cocci

A

Catalase test
+ staph
- strep
- entero

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30
Q

Coag pos and neg staph

A

+ staph aureus
- staph epi

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31
Q

Alpha and beta haemolytic strep

A

A - strep viridans, pneumoniae
B - group A-H strep

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32
Q

Management of staph aureus sepsis

A

IV fluclox
- IV vancomycin if allergic or MRSA

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33
Q

Management coag neg staph sepsis

A

Staph epi
- fluclox resistant
- IV vancomycin

Staph lugdonensis
- high virulence so treat as IV fluclox 2w

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34
Q

What type of strep causes skin and soft tissue infection?

A

Beta haemlytic e.g. strep pyogenes

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35
Q

Main types of bug causing subacute bacterial endocarditis

A

Viridans streptococci and enterococci

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36
Q

How to determine group of beta haemolytic strep?

A

Lancefield antigen
- positive antigen will show agglutination of the sample

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37
Q

Most common strep infection in pregnancy and neonates

A

Group B beta haemolytic strep

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38
Q

Faecalis vs faecium in terms of drug resistance

A

Faecalis - less resistant
Faecium - more resistant

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39
Q

Enterococcus drug resistance

A

(benzyl)Penicillin, Flucloxacillin, cephalosporin
aminoglycosides

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39
Q

Mangement of enterococcus sepsis

A

Amoxicillin
- vanc if amox resistant

If VRE use
- Linezolid
Daptomycin
Tigecycline
Quinupristine/Dalfopristin

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40
Q

Gm pos bacilli include

A

Clostridium
- e.g. c. tetani, diff
Corynebacterium
- c. diptheriae
Bacillus
- b. anthracis, cereus
Listeria
- l. monocytogenes

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41
Q

When is it esp important t consider diptheria?

A

Displaced populations who maybe haven’t been ale to keep up vax status
- good ID as it req antibiotics and specific toxin

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42
Q

WHy is meningitis treated with ceftriaxome AND amoxicillin?

A

Amoxicillin to cover listeria in immunocompromised people

43
Q

Where are difficult to target areas with antibiotics?

A

Central nervous system, eyes, prostate
- site dependent antibiotic treatment

44
Q

When should you consider biofilm?

A

Prosthetic material
- central lines, caths
Cystic fibrosis, bronchiectasis

45
Q

What is mean inhibitory concentration?

A

concentration of drug required for kill of 99.9% of organisms during 18 to 24 hours

46
Q

What might a gm pos bacilli in a blood culture suggest?

A

Intra-abdominal infection
Skin and soft tissue
Prosthetic material (line, device, joint etc)
Meningitis/ encephalitis/ immunosuppressed
PWID/ animal skins/black eschar
Consider contamination

47
Q

Management of septic shock caused by group A strep tinea pedis

A

IV fluclox, clinda, gentamicin
(clinda and gent if pen allergic)
Urgent debridement if nec fac

48
Q

Management sepsis 2o to group A strep tinea pedis

A

IV fluclox (vanc if pen allergic)

49
Q

Watery vs bloody diarrhoea: how can you localise the problem?

A

Watery = small bowel, often viral/parasitic
Bloody = large bowel, often bacterial damage

50
Q

What infection are diabetics more likely to acquire due to glycosuria?

A

Candida

51
Q

5 main mechanisms of immunosuppression

A

Neutropenia e.g. leukaemia
Neutrophil dysfunction e.g. steroids
B cell problems e.g. myeloma
T cell problems e.g. chemo
Anatomic-barrier problems e.g. tumour

52
Q

T cells abnormality immunosuppression puts you at risk of….

A

Weird bugs e.g. fungal

53
Q

Post stroke SOB and cough…

A

Think aspiration pneumonia due to unsafe swallow

54
Q

Recurrent strep pneumo warrants what type of blood test…

A

HIV
- jirovecci is not the only pneumonia assoc with HIV

55
Q

Which patients are at high risk of aspergillosis?

A

Transplant
- depends on course of immunosuppression, vasc factors, steroids, CMV status etc
- due to neutropenia

(cirrhosis, post op ICU, HIV)
A. fumigatus is most common

56
Q

How to investigate aspergillus?

A

Micro and histo of broncho-alveolar lavage

57
Q

2 most common post-flu bacterial infections

A

Strep pneumo
Staph aureus

58
Q

How does klebsiella gram stain?

A

Gram negative
- diverticular abscess, UTI, pneumonia

59
Q

Main bugs coming from unpasteurised dairy

A

Brucella and listeria

60
Q

How long can malaria take to present?

A

Up to 1 year post-travel
- always differential if travel and fever

61
Q

Investigations for possible travel infection exposure

A

BLOOD SMEARS for malaria
FBC
(LFTS)
Blood and other cultures (see history)
Chest x-ray
Urine culture

Always consider acute HIV in non-spec symptoms
ALWAYS CONSULT ID

62
Q

Causes of eosinophilia

A

Helminths
Sometimes viral or fungal pathogens

Also drugs, eczema, allergy, haem malig

63
Q

Clin pres of severe malaria

A

Reduced GCS, seizures , respiratory distress, abnormal bleeding can occur, coma

64
Q

Main type of malaria

A

Plasmodium falciparum

  • 5 types
65
Q

Investigation for malaria

A

3xThick and thin films (over 3 days)
Rapid antigen
Therapy choice depends on suspected species/ geography
Resistance can be a problem esp myanmar/cambodia

66
Q

Clin pres of malaia

A

Palmar and conjunctival pallor
Metabolic acidosis
ARDS
Jaundice
AKI

67
Q

What is enteric fever?

A

Slamonella typhi (thyphid)
- gm neg, treat with gm neg sensitive antibios
Fever and abdo pain
- very faint rash that can be difficult to see on dark skin

68
Q

Describe pres of dengue

A

<14 days return from endemic area
Fever, arthralgia, leukopaenia, shock

Supportive care, no spec antivirals

69
Q

Classic symptoms assoc with dengue

A

Retrobulbar pain
- “pain behind my eye”

Blanching rash
- very dramatic, can see your hand if you press it

70
Q

Name two key viral haemorrhagic fevers

A

Ebola
Lassa

  • very very specific IP protocol
  • spread via contact and droplets
71
Q

4 C antibiotics causing C diff

A

Clindamycin
Ciprofloxacin (and other quinolones)
Co-amoxiclav
Cephalosporins (e.g. ceftriaxone)

72
Q

How can HOME criteria help guide antibiotic treatment?

A

Haemodynamically stable (BP normalises, apyrexial)
Oral route available (switch from IV to PO)
Markers of infection improving (WCC decr)
Exclude deep seated infection source (these req long term IV)

73
Q

How long does VITEK take?

A

24-48h

74
Q

How long does MALDITOF testing take to determine antibiotic sensitivities?

A

6 hours
- super super quick

75
Q

Which side effects do all antibiotics cause?

A

Nausea, vomiting, diarrhoea, rashes, Candida infections

76
Q

In which antibios should you watch LFTs?

A

Fluclox
Co-amox
Macrolides

77
Q

Which class of antibios is now classed as last resort drugs?

A

Quinolones
- due to side effects on QT interval, convulsions, tendonitis

78
Q

Pt turns bright red after a quick bolus dose of which antibiotic…

A

Vancomycin
- red person syndrome
- always given as infusion over hours

79
Q

Enzyme inhibitors cause toxicity of effect of…..

A

Interacting drug
- most antibiotics are enzyme inhibitors

80
Q

Why do you give vancomycin orla for c diff?

A

Local action on the gut
- almost acts as topical antibio
- molecule is too big to pass through gut if it was given IV

81
Q

Pathophysiology of sepsis

A

Inflammation caused by pres of pathogens
Vasodilation occurs to allow products (wcc, plates) to accumulate in affected area
Capillary leakage to mobilise host response to area
Amplified response by cytokine release
Balance between pro-inflam and anti-inflam cytokines becomes deranged

82
Q

Does it matter if infection is confirmed in definition of sepsis?

A

No, def includes suspicion of infection

83
Q

NEWS <5 but followng criteria warrant further action

A

Mottled skin/non-blanching
Cyanosis
>2 lactate
Deteriorating since last assessment/recent intervention
Recent chemo/risk of neutropenia

84
Q

High flow O2 in sepsis 6

A

High flow non rebreather
- to reduce tissue hypoxia
Start if sats <92, aim for 94-98

85
Q

Pts at risk of hypercarbia

A

End stage lung disease
COPD
Neuromusc disorders of chest wall

86
Q

Bloods in sepsis 6

A

At leats 1 set of cultures
- do cultures before FBC
FBC, UEs, LFTs, CRP, clotting, lactate
Consider other more localised cultures by examining pt

87
Q

Why are antibios given in sepsis 6?

A

Source control
Reducing toxin burden/immune stimulus that is driving sepsis
Must be IV, quite broad spectrum
Within 1h

88
Q

Fluid challenge in sepsis

A

Hypovolaemia contirbutes to shock
Sepsis causes fluid in wrong places, want to push it back in
Balance risk of known HF

Challenge with 20ml/kg crystalloid (hartmanns/NaCl/plasmalyte) in boluses and then reassess
- probably around 2L in 250-500ml bolus over 15-20mins

89
Q

Lactate in sepsis 6

A

Risk strat and determine fluid response via measuring tissue hypoperfusion
Highlights pts who aren’t responding properly and may need ref’d up to HD or IC
Hourly via ABG/VBG
- high = tissue ischaemia

90
Q

Urine output in sepsis 6

A

Tells you ab circulation and if BP is sufficient to perfuse kidneys
- low output = poor perfusion
Cath and hourly output monitoring
- targett 0.5ml/kg/hour
- e.g. 30ml /hour in 60kg pt MIN

91
Q

What are you aiming for in hours 2-6 post-sepsis 6?

A

Fluids 20-30ml/kg
MAP >65mmHg
Urine output 30mls
Improved NEWS
Reduced lactate
Haemodynamic stability

92
Q

Concerning signs in pts who are not getting better

A

Worsening confusion
Incr resp rate
Decr BP
Hypoglycaemia

93
Q

Who needs HDU/ICU in sepsis?

A

Non response to interventions
- lactate remains >4 despite 20ml fluid challenge
- MAP <65mmHg (need vasopressors via central line)

Further vasopressor requirement
- ICU

94
Q

Origin of strep viridans

A

GI tract

95
Q

Gm + cocci in chains showing gamma haemolysis

A

Enterococcus faecalis, originates in gut

96
Q

Does gentamicin have anaerobic cover?

A

No

97
Q

What organisms does vancomycin cover?

A

Gm +

98
Q

What type of drug is safe in type 1 penicillin allergy?

A

Aztreonam

99
Q

How many cultures are required before antibios in sepsis?

A

3 sets spaced out over an hour
- then antibios

100
Q

Management of staph aureus bacteraemia

A

IV flucloxacillin
- IV vanc if pen allergic
- treatment min 6 weeks

101
Q

Most commo causative organisms in diverticular abscess

A

Coliforms and anaerobes

102
Q

Oral antibiotics to use after source control of diverticular abscess

A

Oral co trimoxazole and oral metronidazole

103
Q

Management of MRSA bacteraemia

A

IV vancomycin

104
Q

Management of ESBL coliform in blood

A

IV meropenem

105
Q

Is staph aureus coag positive or negative?

A

Positive

106
Q
A

CLASP (3 decks)

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