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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
Fluoroquinolones
-Floxacin
26
Managing atypical non-strep pneumonia
Doxycyline (no kids or pregnant ppl) Clarithromycin Quinolones (c diff risk) Lower mortality than bacterial pneumonia, legionella is higher
27
How can legionella cause infection?
Live in lukewarm aerosolised water ( showers, air conditioning , taps) Multiplies within amoebae and ciliated protozoa Breathing in legionella causes invasion and growth within alveolar macrophages Pontiac fever is less severe disease
28
RFs for legionella infection
smokers, males, COPD, immunosuppressed, malignancy, diabetes, dialysis, hot tubs
29
Test to determine which type of cocci
Catalase test + staph - strep - entero
30
Coag pos and neg staph
+ staph aureus - staph epi
31
Alpha and beta haemolytic strep
A - strep viridans, pneumoniae B - group A-H strep
32
Management of staph aureus sepsis
IV fluclox - IV vancomycin if allergic or MRSA
33
Management coag neg staph sepsis
Staph epi - fluclox resistant - IV vancomycin Staph lugdonensis - high virulence so treat as IV fluclox 2w
34
What type of strep causes skin and soft tissue infection?
Beta haemlytic e.g. strep pyogenes
35
Main types of bug causing subacute bacterial endocarditis
Viridans streptococci and enterococci
36
How to determine group of beta haemolytic strep?
Lancefield antigen - positive antigen will show agglutination of the sample
37
Most common strep infection in pregnancy and neonates
Group B beta haemolytic strep
38
Faecalis vs faecium in terms of drug resistance
Faecalis - less resistant Faecium - more resistant
39
Enterococcus drug resistance
(benzyl)Penicillin, Flucloxacillin, cephalosporin aminoglycosides
39
Mangement of enterococcus sepsis
Amoxicillin - vanc if amox resistant If VRE use - Linezolid Daptomycin Tigecycline Quinupristine/Dalfopristin
40
Gm pos bacilli include
Clostridium - e.g. c. tetani, diff Corynebacterium - c. diptheriae Bacillus - b. anthracis, cereus Listeria - l. monocytogenes
41
When is it esp important t consider diptheria?
Displaced populations who maybe haven't been ale to keep up vax status - good ID as it req antibiotics and specific toxin
42
WHy is meningitis treated with ceftriaxome AND amoxicillin?
Amoxicillin to cover listeria in immunocompromised people
43
Where are difficult to target areas with antibiotics?
Central nervous system, eyes, prostate - site dependent antibiotic treatment
44
When should you consider biofilm?
Prosthetic material - central lines, caths Cystic fibrosis, bronchiectasis
45
What is mean inhibitory concentration?
concentration of drug required for kill of 99.9% of organisms during 18 to 24 hours
46
What might a gm pos bacilli in a blood culture suggest?
Intra-abdominal infection Skin and soft tissue Prosthetic material (line, device, joint etc) Meningitis/ encephalitis/ immunosuppressed PWID/ animal skins/black eschar Consider contamination
47
Management of septic shock caused by group A strep tinea pedis
IV fluclox, clinda, gentamicin (clinda and gent if pen allergic) Urgent debridement if nec fac
48
Management sepsis 2o to group A strep tinea pedis
IV fluclox (vanc if pen allergic)
49
Watery vs bloody diarrhoea: how can you localise the problem?
Watery = small bowel, often viral/parasitic Bloody = large bowel, often bacterial damage
50
What infection are diabetics more likely to acquire due to glycosuria?
Candida
51
5 main mechanisms of immunosuppression
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
T cells abnormality immunosuppression puts you at risk of....
Weird bugs e.g. fungal
53
Post stroke SOB and cough...
Think aspiration pneumonia due to unsafe swallow
54
Recurrent strep pneumo warrants what type of blood test...
HIV - jirovecci is not the only pneumonia assoc with HIV
55
Which patients are at high risk of aspergillosis?
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
How to investigate aspergillus?
Micro and histo of broncho-alveolar lavage
57
2 most common post-flu bacterial infections
Strep pneumo Staph aureus
58
How does klebsiella gram stain?
Gram negative - diverticular abscess, UTI, pneumonia
59
Main bugs coming from unpasteurised dairy
Brucella and listeria
60
How long can malaria take to present?
Up to 1 year post-travel - always differential if travel and fever
61
Investigations for possible travel infection exposure
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
Causes of eosinophilia
Helminths Sometimes viral or fungal pathogens Also drugs, eczema, allergy, haem malig
63
Clin pres of severe malaria
Reduced GCS, seizures , respiratory distress, abnormal bleeding can occur, coma
64
Main type of malaria
Plasmodium falciparum - 5 types
65
Investigation for malaria
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
Clin pres of malaia
Palmar and conjunctival pallor Metabolic acidosis ARDS Jaundice AKI
67
What is enteric fever?
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
Describe pres of dengue
<14 days return from endemic area Fever, arthralgia, leukopaenia, shock Supportive care, no spec antivirals
69
Classic symptoms assoc with dengue
Retrobulbar pain - "pain behind my eye" Blanching rash - very dramatic, can see your hand if you press it
70
Name two key viral haemorrhagic fevers
Ebola Lassa - very very specific IP protocol - spread via contact and droplets
71
4 C antibiotics causing C diff
Clindamycin Ciprofloxacin (and other quinolones) Co-amoxiclav Cephalosporins (e.g. ceftriaxone)
72
How can HOME criteria help guide antibiotic treatment?
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
How long does VITEK take?
24-48h
74
How long does MALDITOF testing take to determine antibiotic sensitivities?
6 hours - super super quick
75
Which side effects do all antibiotics cause?
Nausea, vomiting, diarrhoea, rashes, Candida infections
76
In which antibios should you watch LFTs?
Fluclox Co-amox Macrolides
77
Which class of antibios is now classed as last resort drugs?
Quinolones - due to side effects on QT interval, convulsions, tendonitis
78
Pt turns bright red after a quick bolus dose of which antibiotic...
Vancomycin - red person syndrome - always given as infusion over hours
79
Enzyme inhibitors cause toxicity of effect of.....
Interacting drug - most antibiotics are enzyme inhibitors
80
Why do you give vancomycin orla for c diff?
Local action on the gut - almost acts as topical antibio - molecule is too big to pass through gut if it was given IV
81
Pathophysiology of sepsis
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
Does it matter if infection is confirmed in definition of sepsis?
No, def includes suspicion of infection
83
NEWS <5 but followng criteria warrant further action
Mottled skin/non-blanching Cyanosis >2 lactate Deteriorating since last assessment/recent intervention Recent chemo/risk of neutropenia
84
High flow O2 in sepsis 6
High flow non rebreather - to reduce tissue hypoxia Start if sats <92, aim for 94-98
85
Pts at risk of hypercarbia
End stage lung disease COPD Neuromusc disorders of chest wall
86
Bloods in sepsis 6
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
Why are antibios given in sepsis 6?
Source control Reducing toxin burden/immune stimulus that is driving sepsis Must be IV, quite broad spectrum Within 1h
88
Fluid challenge in sepsis
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
Lactate in sepsis 6
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
Urine output in sepsis 6
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
What are you aiming for in hours 2-6 post-sepsis 6?
Fluids 20-30ml/kg MAP >65mmHg Urine output 30mls Improved NEWS Reduced lactate Haemodynamic stability
92
Concerning signs in pts who are not getting better
Worsening confusion Incr resp rate Decr BP Hypoglycaemia
93
Who needs HDU/ICU in sepsis?
Non response to interventions - lactate remains >4 despite 20ml fluid challenge - MAP <65mmHg (need vasopressors via central line) Further vasopressor requirement - ICU
94
Origin of strep viridans
GI tract
95
Gm + cocci in chains showing gamma haemolysis
Enterococcus faecalis, originates in gut
96
Does gentamicin have anaerobic cover?
No
97
What organisms does vancomycin cover?
Gm +
98
What type of drug is safe in type 1 penicillin allergy?
Aztreonam
99
How many cultures are required before antibios in sepsis?
3 sets spaced out over an hour - then antibios
100
Management of staph aureus bacteraemia
IV flucloxacillin - IV vanc if pen allergic - treatment min 6 weeks
101
Most commo causative organisms in diverticular abscess
Coliforms and anaerobes
102
Oral antibiotics to use after source control of diverticular abscess
Oral co trimoxazole and oral metronidazole
103
Management of MRSA bacteraemia
IV vancomycin
104
Management of ESBL coliform in blood
IV meropenem
105
Is staph aureus coag positive or negative?
Positive
106

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