Sepsis & Severe Infections

Question 1

Define infection.

Answer 1

Invasive + multiplication of pathogenic microbes in an area of the body where they are not normally present, which usually leads to disease

Question 2

Define systemic inflammatory response syndrome (SIRS).

Answer 2

An inflammatory response to infection (or a non-infectious insult) that affects the whole body i.e. is systemic

E.G. pancreatitis, burns, trauma etc.

Question 3

Define sepsis (septicaemia).

Answer 3

When the body’s response to infection causes injury to its own tissues + organs

= known/suspected infection + SIRS

Question 4

What parameters can aid in the diagnosis of systemic inflammatory response syndrome (SIRS)?

Answer 4

Temperature <36 degrees/>38 degrees
HR > 90/min
RR >20/min or pCO2 <32 mmHg
WCC <4x10^9/dl or >12x10^9/dl or >10% immature WBCs
Blood glucose >7.7mmol/l(unless DM present)
Confusion/decreased consciousness (GCS)

Question 5

What is severe sepsis?

Answer 5

Sepsis + organ dysfunction (inc. septic shock)

Question 6

What is septic shock?

Answer 6

Sepsis + hypotension despite fluid resuscitation + perfusion abnormalities e.g. lactic acidosis, decreased UO + Glasgow Coma Scale (GCS)

Question 7

What is the epidemiology of sepsis?

Answer 7

Affects all ages in community + hospital settings

Within top 10 causes of death

Most important cause globally = malaria

Question 8

What is the prognosis of sepsis?

Answer 8

Uncomplicated sepsis: 10% mortality

Severe sepsis: 35% mortality

Septic shock: 50% mortality

Question 9

What is the pathogenesis of sepsis?

Answer 9

Stimulation of IS via microorganism (e.g. PAMP) leading to release of pro-inflammatory cytokines - abnormally large immune response

Question 10

What are the signs and symptoms of sepsis?

Answer 10

• Fever symptoms, vasodilation, increased capillary permeability, increased WBC + activity + decreased myocardial function
• Hypovolaemia, hypoxaemia + hypotension
• Hypoperfusion of tissues
• Anaerobic respiration + acidosis
• End organ damage + multi-organ failure

Question 11

What are the red flags indicating severe sepsis that have been added to help diagnose it?

Answer 11

Purpuric rash
HR >130/min
SBP <90 or MBP <65 mmHg
RR >25/min
O2 sats <91%
Decreased GCS 
Lactate >2mmol/l

Question 12

Why do more definitions and parameters keep getting added to the definitions of sepsis?

Answer 12

Because they are impossible to define and include such a wide variety of symptoms + we do not want to miss any cases of it due to high mortality -> we want a precise + simple definition that uses biomarker results too

Question 13

What is the clinical criteria to diagnose sepsis?

Answer 13

Infection + SOFA (sepsis-related organ failure assessment) score of > 2

Question 14

What criteria are involved in the SOFA test?

Answer 14

Low pO2/FiO2 ratio
Hypotension OR vasopressors
Platelets
Decreased GCS
Increased bilirubin
Increased creatinine + oliguria

Question 15

What is the sepsis bedside criteria?

Answer 15

quick SOFA (qSOFA)

Question 16

What criteria are involved in the qSOFA test?

Answer 16

Infection + 1 or more of these symptoms:
RR > 22
Altered cognition/low GCS
SBP < 100 mmHg

Question 17

Define SOFA.

Answer 17

A comprehensive scoring system used in intensive care which outputs a sequential organ failure assessment score

Question 18

Define qSOFA.

Answer 18

Quick SOFA

An abbreviated score used in screening for sepsis

Question 19

What types of infections can cause severe sepsis?

Answer 19

• CNS (meningitis + encephalitis)
• LRT (pneumonia)
• Infective endocarditis (heart valves + prostheses)
• Infective gastroenteritis (bacterial)
• UTI (pyelonephritis)
• Skin + soft tissue infections (cellulitis + necrotising faciitis)
• Bone + joint infections (osteomyelitis + septic arthritis)
• Undifferentiated febrile illnesses (malaria + enteric fever etc.)

Question 20

Within 1 hour of suspecting severe sepsis, you must give the sepsis six care bundle. What are the 6 steps involved in this?

Answer 20

1. Give high flow O2
2. Blood cultures
3. Empirical IV antibiotics
4. Measure FBC + serum lactate
5. Start IV fluid resuscitation
6. Start accurate UO measurements

Question 21

If the patient does not respond to the sepsis six care bundle, what should your next move be?

Answer 21

Critical care + further bundles

E.G. resuscitation bundle (early goal directed therapy) = CVP monitoring, vasopressor drugs + inotropic drugs

OR

Other treatments may be indicated e.g. steroids + ventilation

Question 22

What sepsis protocols + antibiotic guidelines are available to help you deal with sepsis?

Answer 22

Surviving sepsis campaign (sepsis protocols + bundles)
Local sepsis protocols (often simpler)
BNF (generic antibiotic guidelines)
Local antibiotic guidelines

Question 23

What 2 things majorly increase the mortality of sepsis?

Answer 23

1. The longer a patient has had hypotension for

2. The longer delay there is in antibiotic commencement