Sepsis and Severe infections Flashcards
What is SIRS?
Systemic inflammatory response syndrome Describes disseminated inflammation in response to a variety of clinical insults.
How is SIRS recognised?
Clinically recognised by the presence of two or more of the following:
Temperature >38.5
Heart rate >90bpm
Resp rate > 20 breaths/min
WCC >12
Define sepsis
SIRS resulting from a documented infection
Define severe sepsis
Sepsis associated with organ dysfunction, hypoperfusion or hypotension.
What is septic shock?
Severe sepsis with hypotension (systolic BP 40 mmHg from baseline) that is unresponsive to adequate fluid resuscitation.
How would you treat a patient you suspected to have severe sepsis?
Sepsis 6
- Give high flow oxygen
- Take blood cultures
- Give empirical IV antibiotics
- Measure FBC and serum lactate
- Give IV fluid resuscitation
- Measure urine output
State how you would assess organ dysfunction for 3 organs
Respiratory failure: Oxygen requirements
Circulatory failure: Low BP, high lactate, mottling
Renal failure: Urine output / Creatinine
CNS: Glasgow coma score
Coagulation: Low platelets, DIC
Liver: Lactate, low glucose
Name two causes of bacterial meningitis
- N. meningitidis
- S. pneumoniae
Also: Group B streptococci
Haemophillus influenzae
Listeria monocytogenes
Mycobacterium tuberculosis.
Name two causes of viral meningitis
Enterovirus, VZV, HIV, mumps, measles
What are the three cardinal symptoms of meningitis?
Fever/headache, neck stiffness, photophobia
Name two causes of encephalitis
HSV, Rabies Also: VZV, HIV, arboviruses
How can you distinguish between a patient with meningitis and encephalitis
Both meningitis and encephalitis present as fever, headache and neck stiffness. In encephalitis because the brain tissue is infection patients also experience reduced consciousness, confusion and seizures
Why is a CT scan sometimes done before a lumbar puncture
Suspected mass or fluid raising intracranial pressure, could cause cerebellar herniation. Unconscious patients
What investigations are done in patients with CNS infections?
WCC
Blood cultures
Blood tests for antigen/PCR
Urine analysis for antigens
Throat swabs
Serology
CSF analysis from lumbar puncture
How is CSF analysed to determine cause of meningitis?
Cloudy appearance = bacterial meningitis
WCC: mostly neutrophils = bacterial, mostly lymphocytes = viral or TB
High protein = bacterial or TB meningitis
Low blood glucose = bacterial or TB meningitis
What are the treatments for meningitis?
Bacterial: ceftriaxone and dexamethasone (vancomycin + rifampicin in penicillin allergy)
Viral: aciclovir
TB: rifampicin, isoniazid, pyrazinamide, ehambutol and dexamethosone
Why is the incidence of MenB type bacterial meningitis higher than other serotypes?
No vaccine exists for MenB
Glasgow Coma Scale
Best motor response : Obeys commands 6
Localising response to pain 5
Withdraws from pain 4
Flexor (decorticate) response 3
Extensor (decerebrate) response 2
No response 1
Best verbal response : Normal speech 5
Confused speech 4
Inappropriate speech (words only) 3
Incomprehensible (sounds only) 2
No response 1
Best eye response : Eyes open spontaneously 4
Eyes open to voice 3
Eyes open to pain 2
No response 1
Impetigo
Superficial skin disease common in children. Presents as weeping, exudative areas with honey-crust on the surface. Spread by direct contact. Caused by stapylococci (S. aureus) or BH-streptococci. Treated topically with fusidic acid or 1 week course of antibiotics
Erysipelas
Superficial infection of the dermis and upper subcutaneous layer of the face. Clearly defined. Caused by steptococci
Cellulitis
Hot, tender area of confluent erythema of the skin due to infection of deep subcutaneous tissue that spreads underneath the skin.
Often affects the lower leg. Pain at the site of inflammation in response to pressure
Caused by streptococcus (sometimes staph).
Athletes foot, fungal infections, diabetes at highest risk.
Treated with flucloxacilin (+ benzylpenicillin) N.B. can be mistaken for chronic venous insufficiency which is caused by poor circulation due to obesity
Necrotising fascilitis
Rapid spreading infection associated with widespread tissue destruction through all layers of the tissue. Commonly caused by GroupA Streptococci.
Characterised by severe pain beyond the site of initial infection followed by tissue necrosis. Infection spreads along the tissue causing spreading erythema, pain and sometimes creptius (from gas produced by bacterial respiration).
Clinical features: sepsis, discolouration (purple/black), pain and tenderness Investigations: indicators of sepsis, raised creatine kinase (if muscle involved), gas in soft tissues (late!)
Treatment: treat sepsis. Antibiotics (IV meropenem and IV clindamycin), surgical debridement
Undifferentiated febrile illness
Multiple infectious causes. Must take travel history, and full systems review. Incubations periods of infections can be an indicator.
Initial treatment is resuscitation and broad spectrum antibiotics. Blood investigations: FBC, ESR, U+E, LFT, CRP Microscopy: Blood, Urine, (sputum, faeces, CSF) Imaging: CXR, Echo, USS abdomen and pelvis
What are the signs and symptoms of benign malaria?
hot and cold sweats arthralgia + myalgia hepatosplenomegaly headache diarrhoea and vomiting anaemia
What are the signs and symptoms of falciparum malaria?
hypoglycaemia
haemorrhage
renal failure
coagulopathy
septic and hypovolemic shock
respiratoy failure
What investigations can be carried out for malaria?
Antigen test (ELISA kit) blood film
What is the treatment for malaria?
Benign malaria: chloroquine for 2days, followed by primaquine to eradicate
Falciparum malaria: quinine for 7 days followed by doxycycline for 7 days.
Treatment for necrotising fascilitis
Sepsis 6 IV
meropenem and clindamycin
Surgical debridement
How would you treat cellulitis?
Flucoxacillin + benzylpenicillin to target S> aureus and beta-haemolytic strep
