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.
