Sepsis Flashcards
What is SIRS?
Systemic inflammatory response syndrome = a clinical response arising from a non-specific insult
What can sepsis lead to?
Tissue damage, organ failure, death
What are the stages of sepsis?
1) Infection/trauma
2) SIRS
3) Sepsis syndrome
4) Severe sepsis
How do you diagnose SIRS?
1) Temp ≥ 38 or ≤ 36 (some elderly people decrease temp) 2) HR ≥ 90 3) RR ≥ 20 (or PaCO2 < 32 mmHg) 4) WCC ≥ 12,000/mm3 or ≤4,000/mm3 (some elderly people can lose white cells) or >10% immature forms
What is sepsis syndrome?
SIRS with a presumed or confirmed infectious process
What is severe sepsis?
Sepsis with > 1 sign of organ failure/acute organ dysfunction (incl. hypoperfusion and hypotension) caused by sepsis:
1) Cardiovascular (refractory hypotension) - shock
2) Renal
3) Respiratory
4) Hepatic
5) Haematologic
6) CNS
7) Unexplained metabolic acidosis
What is sepsis?
- At least two SIRS criteria cause by known or suspected infection
- Life threatening organ dysfunction caused by abnormal response to infection
What is septic shock?
- Sepsis with persistent or refractory hypotension or tissue hypoperfusion despite adequate fluid resuscitation
- Sepsis where medication is required (vasopressors) to maintain BP
What is the main fungus that causes sepsis (fungaemia)?
Candida
What is the main parasite that causes sepsis (parasitaemia)?
Malaria
What microbial components trigger shock?
1) Endotoxin (LPS) - gram negative
2) Lipoteichoic acid - gram positive
3) Direct - vascular endothelium injury
What are the immune mediators of the shock response?
1) Toll like receptors
2) Complement cascade
3) Coagulation cascade via cytokines IL-1, IL-6, TNF
4) Depletion of protein C
What are superantigens?
Antigens produced by certain Group A strep and staph aureus TSST-1 which bypass the normal antigen response
How does organ failure occur in sepsis?
1) Vasodilation, decreased blood pressure and red cell deformability and thrombosis leads to tissue hypoperfusion
2) This, loss of barrier function due to cell shrinkage and death and mitochondrial dysfunction leads to decreased tissue oxygenation and organ failure
Why do you need to interfere within the 1st hour of presentation of sepsis?
Bc of the vicious cycle of inflammation and coagulation which can quickly lead to death
What are the main gram negative causes of infection-related shock mortality?
1) E.coli (and other coliforms)
2) Meningococci
3) Pseudomonas (device/CF associated chest infection)
4) Haemophilus (flu and pneumonia)
5) Klebsiella
What are the main gram positive causes of infection-related shock mortality?
1) Staph aureus
2) Group A streptococci (S.pyogenes)
3) S. pneumoniae
4) Clostridium
5) Enterococcus
What is the main viral cause of infection-related shock mortality?
Viral haemorrhagic fevers
What are 3 causes of neonatal sepsis?
1) Group B strep
2) Listeria
3) E.coli
What are the most common infections associated with septicaemia and shock (that get into bloodstream)?
1) Severe UTI with pyelonephritis (kidneys to blood)
2) Meningococcal disease
3) Gut perforation
4) Infection of IV lines, catheters and devices
5) Skin and soft tissue infection (SSTIs)
6) Endocarditis (heart valves, direct access to blood)
7) Pneumonia
8) Cholecystitis, cholangitis, pancreatitis e.g. fatal peritonitis from ruptured appendix with purulent exudate in right colic gutter
How would you diagnose sepsis using investigations?
1) Clinical according to sepsis criteria
2) Determine the site of origin/specific cause
3) Blood cultures (incl. through catheters) - collect before abx which need to be given in first hour
4) Cultures of urine, IV lines, pus etc
5) Blood tests incl. WCC, CRP, LFTs etc
What are the differential diagnoses in septic shock?
1) Burns, trauma, pancreatitis
2) PE, ruptured AAA, haemorrhage
3) MI, cardiac tamponade, drug overdose
4) Adrenal insufficiency
5) Anaphylaxis
How would you manage sepsis?
1) Fluids, dopamine, transfusion (ICU)
2) Resolution of precipitating problems
3) Monitor blood gases, renal function, CNS, GCS< LFTs, myocardial function
4) Antimicrobials
What are negative outcomes of sepsis?
1) Mortality 30-60%
2) Multi-organ failure
3) Loss of extremities
4) Prolonged hospital stay and costs
What is the sepsis six?
A set of interventions which can be delivered by any junior HCP working as part of a team
What are the 6 interventions that are part of the sepsis six?
1) Administer high flow oxygen for hypoxia
2) Take blood cultures
3) Give broad spectrum abx
4) Give IV fluid challenges
5) Measure serum lactate and Hb
6) Measure accurate hourly urine output
What are the antimicrobial prescribing recommendations in sepsis?
1) Begin IV abx as early as possible and within first hour of recognising severe sepsis/shock
2) Start with broad spectrum
3) Consider combination empiric therapy in neutropenic patients (more bacteria can cause sepsis)
4) Combination therapy for no more than 3-5 days
5) De-escalation following susceptibilities and organism identity
What is the duration of antimicrobial therapy in sepsis?
- 7-10 days
- Longer if response is slow, undrainable foci (site of infection, depends on how easily you can surgically drain) or immunological deficiencies
What antibiotics would you give if the origin of community acquired shock is unknown, gut, renal or binary?
- Co-amoxiclav + gentamicin (+ vancomycin if ?MRSA)
- OR cefuroxime/ciprofloxacin + metronidazole then gentamicin
What antibiotics would you give if the origin of community acquired shock is skin or soft tissue infection?
- Flucloxacillin + penicillin (or amoxicillin)
- ± gentamicin
- Consider adding clindamycin if group A strep or S.aureus toxic shock
What antibiotics would you give if the origin of community acquired shock is pneumonia?
- Co-amoxiclav + doxycycline
- OR cefuroxime + erythromycin
What antibiotics would you give if the origin of community acquired shock is meningococcal disease?
- Penicillin or ceftriaxone
What antimicrobial would you give if the origin of community acquired shock is malaria?
Quinine
What antibiotics would you give for community acquired shock if there is a penicillin or cephalosporin allergy?
1) If rash only consider using a penicillin or cephalosporin depending on the allergy
2) If severe use agents such as ciprofloxacin, vancomycin, erythromycin (get advice)
How would you treat hospital acquired infection shock?
- Gentamicin + piperacillin-tazobactam
- Check recent cultures and antibiotics received
What bacterial causes should you consider if the hospital acquired infection shock is due to prolonged admission or device related?
1) MRSA (vancomycin)
2) ESBL positive GNR (highly resistant GNR)
3) VRE (linezolid and others)
How else would you manage sepsis other than medications?
1) Remove infected catheters and devices
2) Drain pus, debride dead tissue (abx don’t read centre of abscess - abscess is avascular structure)
3) Consider lessening immunosuppression therapies
4) Fluid balance
5) Check gentamicin or vancomycin levels
How can sepsis be prevented?
- Wound care esp. in diabetic foot patients
- Vaccination
- Hand washing
Which organ is likely to have mixed organisms causing sepsis?
Gut (e.g. E.coli and enterobacter) - not lungs or brain
How would someone with a perforated appendix and peritonitis present?
- Extreme pain with peritonism
- Fever
- Low BP
- High pulse
- High WCC
- Normal Hb
- Low platelets
- Slightly hypoxic
How would you manage someone with a perforated appendix and peritonitis?
- Take to theatre
- MRI scan of abdomen
- Start on co-amoxiclav + gentamicin
- Culture pus and blood + antibiotic sensitivities
Would you check blood levels of co-amoxiclav?
No
What scan would you do to see an abscess?
CT (USS)
What would indicate the presence of an abscess after ruptured appendix and peritonitis?
Relapse with fevers but not as ill - low albumin?
What should gentamicin levels be?
< 1mg/L pre-dose after 24h
How would you treat an abscess?
Drainage of pus, washout, (ileostomy), antibiotics, culture pus
Why would you not change to a single antibiotic in gut sepsis even if have cultured e.g. E.coli?
- Could also be other bacteria bc perforated appendix
- Unlike UTI where could do this bc usually single organism cause
What are the key features of sepsis?
1) Low BP - systolic < 100
2) High RR - > 22
3) Confused
4) Venous lactate > 2
How do you treat sepsis?
- Oxygen
- IV fluids
- Antibiotics
- Source control
