Sepsis following Pregnancy, Bacterial Flashcards
Risk factors for maternal sepsis as identified by the Confidential Enquiries into Maternal Deaths
1 - Obesity
2 - Impaired glucose tolerance/diabetes
3 - Impaired immunity / immunosuppressant medication
4 - Anaemia
5 - Vaginal discharge
6 - History of pelvic infection
7 - Amniocentesis and other invasive procedures
8 - Cervical cerclage
9 - Prolonged spontaneous rupture of membranes
10 - Vaginal trauma, CS, wound haematoma
11 - Retained products of conception
12 - GAS infection in close contacts / family members
13 - Black or minority ethnic group origin
The major pathogens causing sepsis in the puerperium are:
● GAS, also known as Streptococcus pyogenes
● Escherichia coli
● Staphylococcus aureus
● Streptococcus pneumoniae
● meticillin-resistant S. aureus (MRSA), Clostridium septicum and Morganella morganii.
What are the likely causes of sepsis outside the genital tract and how might they be identified?
- general history and examination: to try and identify source of sepsis.
- Women should be assessed clinically and, if unwell or with dehydration or vomiting, admission considered.
Common symptoms of sepsis in the puerperium
1 - Fever, rigors (persistent spiking temperature suggests abscess). Beware: normal temperature may be attributable to antipyretics or NSAIDs
2 - Diarrhoea or vomiting – may indicate exotoxin production (early toxic shock)
3 - Breast engorgement / redness
4 - Rash (generalised maculopapular rash)
5 - Abdominal /pelvic pain and tenderness
6 - Wound infection – spreading cellulitis or discharge
7 - Offensive vaginal discharge (smelly: suggestive of anaerobes; serosanguinous: suggestive of streptococcal infection)
8 - Productive cough
9 - Urinary symptoms
10 - Delay in uterine involution, heavy lochia
11 - General – non-specific signs such as lethargy, reduced appetite.
What is the optimum way to monitor women with suspected sepsis in the puerperium?
- Monitoring of suspected severe sepsis or established sepsis: MDT but preferably under leadership of single consultant. A senior obstetrician with intensivist, microbiologist or infectious disease clinician.
- Regular observations of all vital signs (including temperature, pulse rate, blood pressure & respiratory rate): recorded on modified early obstetric warning score (MEOWS) chart.
What infectious disease history/information should be noted?
- Any recent illness or exposure to illness in close contacts, particularly streptococcal infections, noted.
What are the appropriate triggers or features of sepsis in the puerperium that should prompt hospital admission?
- Community carers be aware of importance of early referral to hospital of recently delivered who feel unwell and have pyrexia, & possibility of sepsis in puerperium.
- If sepsis is suspected in community, urgent referral to hospital is indicated
‘Red flag’signs and symptoms (see below) should prompt urgent referral for hospital assessment and, if woman appears seriously unwell, by emergency ambulance:
● pyrexia more than 38°C
● sustained tachycardia more than 90 beats/minute
● breathlessness (respiratory rate more than 20 breaths/minute; a serious symptom)
● abdominal or chest pain
● diarrhoea and/or vomiting
● uterine or renal angle pain and tenderness
● woman is generally unwell or seems unduly anxious or distressed.
What are the appropriate triggers for involvement of other specialties?
- All cases of sepsis in puerperium discussed with clinical microbiologist or infectious diseases physician. Appropriate specimens sent for urgent examination. Antimicrobials started within 1 hour of recognition of severe sepsis.
- Women previously documented carriage of or infection with multiresistant organisms (e.g. ESBL producing organisms, MRSA, GAS or PVL-producing staphylococci) prompt notification of infection control team.
- Suspicion of necrotising fasciitis prompt involvement of intensive care physicians and referral for surgical opinion, ideally from plastic and reconstructive surgeons if available.
What investigations should be performed?
- Blood cultures: key investigation & obtained prior to antibiotic administration; however, antibiotic treatment started without waiting for microbiology results.
- Serum lactate: measured within 6 hours of suspicion of severe sepsis to guide management. Serum lactate ≥ 4 mmol/l is indicative of tissue hypoperfusion.
- Any relevant imaging studies performed promptly in attempt to confirm source of infection. This could include a chest X-ray, pelvic ultrasound scan or computed tomography scan if pelvic abscess is suspected.
- Other samples taken should be guided by clinical suspicion of focus of infection as appropriate.
- Routine blood tests: FBC, urea, electrolytes and CRP.
- Any woman: symptoms of tonsillitis/pharyngitis throat swab sent for culture.
- If MRSA status of woman unknown, premoistened nose swab may be sent for rapid MRSA screening where such testing is available.
Tasks to be performed within the first 6 hours of the identification of severe sepsis; modified from
the Surviving Sepsis Campaign Resuscitation Bundles
- Obtain blood cultures prior to antibiotic administration
- Administer broad-spectrum antibiotic within 1 hour of recognition of severe sepsis
- Measure serum lactate
- If hypotension and/or a serum lactate > 4 mmol/l:
@ initial minimum 20 ml/kg of crystalloid or an equivalent
@ vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure > 65 mmHg - If persistent hypotension despite fluid resuscitation (septic shock) &/or serum lactate > 4 mmol/l:
@ Achieve CVP of ≥ 8 mmHg
@ Achieve central venous oxygen saturation ≥ 70% or mixed venous oxygen saturation ≥ 65%
How should sepsis in the puerperium be managed?
- focus of infection sought & dealt with. maybe by uterine evacuation or by drainage of breast, wound or pelvic abscess.
- Broad-spectrum antibiotics should be given to cover these procedures.
Which antibiotics should be used?
- Administration of IV broad-spectrum antibiotics within 1 hour of suspicion of severe sepsis, with or without septic shock, is recommended as part of the Surviving Sepsis resuscitation care bundle.
- If genital tract sepsis suspected, prompt early treatment with combination of high-dose broadspectrum IV antibiotics may be life saving.
- combination of either piperacillin/tazobactam or carbapenem plus clindamycin: one of broadest ranges of treatment for severe sepsis.
- MRSA may be resistant to clindamycin, hence if or highly likely to be MRSA-positive, glycopeptide such as vancomycin or teicoplanin maybe added until sensitivity known.
- Breastfeeding limits use of some antimicrobials, hence advice of consultant microbiologist should be sought at an early stage.
Antimicrobial choices and limitations of antimicrobials
Antimicrobial Limitations
- Co-amoxiclav: Does not cover MRSA, Pseudomonas or ESBL-producing organisms
- Metronidazole: Only covers anaerobes
- Clindamycin Covers most streptococci & staphylococci, including many MRSA, and switches off exotoxin
production with significantly decreased mortality
Not renally excreted or nephrotoxic - Piperacillin/tazobactam and carbapenems: Covers most organisms except MRSA and are renal sparing (in contrast to aminoglycosides) Piperacillin/tazobactam does not cover ESBL producers
- Gentamicin (as a single dose of 3–5 mg/kg) Poses no problem in normal renal function but if doses are to be given regularly serum levels must be monitored
What is the role of intravenous immunoglobulin (IVIG)?
IVIG: recommended for severe invasive streptococcal or staphylococcal infection if other therapies failed.
Where should women with sepsis be cared for?
- sepsis in puerperium are best managed in hospital where diagnostic services are easy to access & intensive care facilities are readily available.
- Early referral to hospital may be life saving.
What are the indications for admission to the intensive care unit (ICU)?
- presence of shock or other organ dysfunction in woman is an indication for admission to ICU.
Indications for admission of the woman to the ICU;3 adapted from Plaat and Wray,
- Cardiovascular: Hypotension or raised serum lactate persisting despite fluid resuscitation suggesting need for inotrope support
- Respiratory: Pulmonary oedema, Mechanical ventilation
Airway protection - Renal Renal: dialysis
- Neurological Significantly decreased conscious level
- Miscellaneous: Multiorgan failure, Uncorrected acidosis
Hypothermia
How should a drug-misusing woman be managed?
- history of substance misuse: usually monitored under multiagency care. local drugs advisory specialist team & existing hospital guidelines for care of substance misusers /drug users should be consulted.
- Any injection-site lesions should be swabbed and an MRSA screen performed
What are the infection control issues?
- isolated in single room with en suite facilities to reduce risk of transmission of infection.
- HCP (doctors, midwives, nurses, anaesthetists & members of wound care team) wear PPE including disposable gloves and aprons when in contact with woman, equipment and their immediate surroundings.
- Breaks in skin of woman or carer must be covered with a waterproof dressing.
- Fluid-repellent surgical masks with visors must be used at operative debridement /change of dressings of GAS necrotising fasciitis and for other procedures where droplet spread is possible.
- Visitors: offered suitable information and relevant PPE while woman is isolated.
What are the neonatal issues if sepsis develops in the puerperium?
- The baby is especially at risk of streptococcal and staphylococcal infection during birth and during breastfeeding. The umbilical area should be examined and a paediatrician consulted in the event of sepsis in the puerperium.
- If either the mother or the baby is infected with invasive GAS in the postpartum period, both should be
treated with antibiotics
What are the indications for prophylaxis to family/staff?
- Close household contacts should be warned about the symptoms of GAS infection and told to seek medical attention should symptoms develop. Asymptomatic contacts may warrant prophylaxis.
- Local and national guidelines should be followed in consultation with the local health protection unit or
consultant for communicable disease control.
Can sepsis in the puerperium be prevented or detected earlier?
- All pregnant and recently delivered women should be informed of the signs and symptoms of genital
tract infection and how to prevent its transmission. - Any GAS identified during pregnancy should be treated aggressively.
Diagnostic criteria for sepsis modified from Levy et al.,
using CMACE1 and Lewis2 where pregnancy-specific
parameters available.
Infection, documented or suspected, and some of the following:
General variables:
1 - Fever (> 38ºC)
2 - Hypothermia (core temperature < 36ºC)
3 - Tachycardia (> 90 beats/minute)
4 - Tachypnoea (> 20 breaths/minute)
5 - Impaired mental state, altered conscious level
6 - Considerable oedema or positive fluid balance (> 20ml/kg over 24 hours)
7 - Hyperglycaemia in the absence of diabetes (plasma glucose > 7.7 mmol/l)
8 - Bruising or discoloration of skin suggests late fasciitis (often pain receding as cutaneous anaesthesia supervenes as nerves die)
Inflammatory variables:
1 - White blood cell (WBC) count > 12 x 109l
2 - Leucopenia (WBC count < 4 x 109l)
3 - Normal WBC count with > 10% immature forms
4 - Plasma C-reactive protein > 7mg/l (usually significantly higher in bacterial sepsis)
Haemodynamic variables:
1 - Arterial hypotension (systolic blood pressure < 90mmHg; mean arterial pressure < 70mmHg; or systolic blood pressure decrease > 40mmHg)
Tissue perfusion variables:
1 - Raised serum lactate ≥ 4 mmol/l
2 - Decreased capillary refill or mottling
Organ dysfunction variables:
1 - Arterial hypoxaemia (PaO2 (partial pressure of oxygen in arterial blood) /F IO2 (fraction of inspired oxygen) < 40kPa); sepsis is severe if < 33.3kPa in the absence of pneumonia or < 26.7kPa in the presence of pneumonia
2 - Oliguria (urine output < 0.5ml/kg/hr for at least two hours, despite adequate fluid resuscitation)
3 - Creatinine rise of > 44.2µmol/l; sepsis is severe if creatinine level > 176µmol/l
4 - Coagulation abnormalities (International Normalised Ratio [INR] > 1.5 or activated partial thromboplastin time [APTT] > 60 seconds)
5 - Thrombocytopaenia (platelet count < 100 x109/l)
6 - Hyperbilirubinaemia (plasma total bilirubin > 70µmol/l)
7 - Ileus (absent bowel sounds)
Staphylococcal toxic shock syndrome (TSS): clinical disease definition.
- Fever > /= 39.9°C
- Rash: diffuse macular erythema
- Desquamation: 10–14 days after onset of illness, especially palms and soles
- Hypotension: systolic BP < 90 mmHg (adults)
_________________________________________ - Multisystem involvement: Three or more of following
systems affected:
● gastrointestinal: vomiting or diarrhoea at onset of illness
● muscular: severe myalgia or elevated creatinine phosphokinase
● mucous membranes: vaginal, oropharyngeal or conjunctival hyperaemia
● renal: creatinine twice the upper limit of normal
● hepatic: total bilirubin twice the upper limit of normal
● haematological – platelets ≤ /= 100 x 109/l
● central nervous system – disorientation or alterations in
consciousness without focal neurological signs
_________________________________
Case classification:
Probable: 4 of the 5 clinical findings positive
Confirmed: case with all 5 clinical findings
Streptococcal toxic shock syndrome (STSS): clinical disease definition.
A. Isolation of group A Streptococcus from:
1. normally sterile site: blood, cerebrospinal fluid, peritoneal fluid, tissue biopsy
2. non-sterile site: throat, vagina, sputum
_____________________________
B. Clinical case definition
Multi-organ involvement characterised by:
1. hypotension
plus
2. two or more of the following:
● renal impairment – creatinine >176µmol/l
● coagulopathy – platelets < 100 x 109/l or disseminated intravascular coagulation
● liver involvement: alanine transaminase or aspartame transaminase or bilirubin levels twice the normal upper limit for age
● acute respiratory distress syndrome
● generalised erythematous macular rash (present in 10%):
may desquamate
● soft tissue necrosis including necrotising fasciitis, myositis or gangrene
__________________________________
Case classification:
Probable: meets clinical case definition (above) plus isolation from non-sterile site
Definite: meets clinical case definition (above) plus isolation of group A Streptococcus from a normally sterile site
ANAEROBES:
Clostridia/
Bacteriodes/
Peptostreptococci
Ampicillin Co- amoxiclav Clindamycin Imipenem/ Meropenem/ Tazocin Vancomycin/Teicoplanin/Linezolid/Daptomycin Erythromycin Metronidazole
MRSA
Gentamycin Trimethoprim (small) Clindamycin (small) Vancomycin/Teicoplanin/Linezolid/Daptomycin Erythromycin (small)
GRAM POSITVE:
Staph. aureus
(fluclox sensitive)
Gentamycin Trimethoprim Ampicillin ( small) Co- amoxiclav Cefuroxime/cefotaxime Clindamycin Imipenem/ Meropenem/ Tazocin Vancomycin/Teicoplanin/Linezolid/Daptomycin Erythromycin
Group A strep/
Group B strep
Trimethoprim Ampicillin Co- amoxiclav Cefuroxime/cefotaxime Clindamycin Imipenem/ Meropenem/ Tazocin Vancomycin/Teicoplanin/Linezolid/Daptomycin Erythromycin
GRAM NEGATIVE:
Coliform
Gentamycin Trimethoprim Ampicillin (small) Co- amoxiclav Cefuroxime/cefotaxime Imipenem/ Meropenem/ Tazocin
GRAM NEGATIVE:
Pseudomonas
Gentamycin
Imipenem/ Meropenem/ Tazocin
What should prompt recognitiion of sepsis in puerperium?
- All HCP aware of sign & symptoms of maternal sepsis
& critical illness & of rapid, potentialy lethal course of severe sepsis & septic shock. Suspision of sinificant sepsis trier urent referral to secondary care. - Clinical sins suggestive of sepsis include one or more of following: pyrexia, hypothermia, tachycardia, tachypnoea, hypoxia, hypotension, oliguria, impaired consciousness &failure to respond to treatment. These sins, including pyrexia, may not always be present & not necessarily related to severity of sepsis.
- Mastitis must never be overlooked.
- Abdominal pain, fever (>38 C) & tachycardia (>90 bpm) in puerperium) indication of IV antibiotics & senior clinical review.
- NSAIDs avoided for pain relief in cases of sepsis as they impede ability of poly morphs to fight GAS
