Sepsis/Shock Flashcards
Sepsis
Life-threatening organ dysfunction caused by a dysregulated host response to infection
Criteria
-Infection plus
-Increase in SOFA by 2+
=
-Hypotension (needing vasopressors to have MAP at 65+)
-Serum lactate > 18 (> 2) despite fluid resuscitation
Monitoring of Sepsis
Send cultures before starting abx
-Temp, vitals, CBC, PCT
-Xray, US, CT, MRI
-Chemistry, lactate, blood gas, coags
Initial ABX Tx Time
-Administer IV abx within 1 hour if shock is present
-Within 3 hours if shock is not present
-Initiate empiric, broad-spectrum therapy with ≥ 1 agent(s) active against likely pathogens
Unknown Source = Etiology
Gram +
-MSSA, MRSA, S. pneumoniae, enterococcus
Gram -
-Pseudomonas, enterobacter spp., E.coli, klebsiella
Fungal
-Candida, aspergillus, crypt, cocci
Empiric Regimen Should Cover:
- Gram negative and positive organisms
- ± MRSA
- ± anaerobes
Empiric Monotherapy
- 3rd-4th generation cephalosporins
- Beta-lactam combination agents (e.g., Zosyn)
- (Quinolone)
- Carbapenems
~Use prolonged infusions
Consider double coverage for:
- Septic shock or neutropenic at high risk for MDR bugs
- MDR Pseudomonas or GNR
- Risk Factors for above:
= RR HD 909090
-Proven infection with resistant bugs in the prior year
-Local prevalence of resistant organisms
-Hospital or healthcare-associated infection
-Broad spectrum abx within 90 days
-Selective digestive decontamination
-Travel to highly endemic country within 90 days
-Hospitalization abroad within 90 days
Cephalosporins: Limitations, Dosing (empiric)
Cefepime 1-2 g Q8-12
Cefotaxime 1.5 g Q12
Ceftazidime 1 g Q8
alphabetical order, lowest to highest PIME TAX TAZ
Holes in spectrum: for MRSA, enterococcus, anaerobes
B-lactam Combos: Limitations, Dosing (empiric)
Ticarcillin/Clav 3.1 g Q4-6
Pip/Tazo 3.375 g Q6-8
Holes in spectrum: for MRSA, VRE, ESBL organisms
Carbapenems: Limitations, Dosing (empiric)
Meropenem 0.5-1 g Q8
Imipenem 0.5-1 g Q6-8
Doripenem 0.5 g Q8
Holes in spectrum: for MRSA, VRE, CoNS, C. diff, Stenotrophomonas, atypicals
Empiric Gram (+) Therapy
- Cover Gram (+) for all patients with sepsis
- Consider adding MRSA coverage if SHMADD
-Prior history of MRSA infection
-Recent IV antibiotics
-Hx of recurrent skin infections or chronic wounds
-Presence of invasive devices, hemodialysis
-Recent hospital admissions or high severity of illness - Discontinue if gram (+) organisms are ruled out
- Not recommended as empiric monotherapy
Empiric Anti-Fungal Therapy
NOT recommended empirically
Consider in high risk pts:
-Prior fungal infection
-Prior exposure to prophylactic or therapeutic antifungals
-Immunosuppressed or neutropenic
-Prolonged LOS, devices/lines, TPN
-GI perforation or leakage, recent abdominal surgery
Caspofungin, Fluconazole, Voriconazole, Ampho B
Antibiotic Therapy - Guidelines
HC/IC
-ZAMCC + VL +/- MCLT
(zosyn, azt, ceftaz, cefepime, meropenem), VL, (tobra, levo, cipro, micafungin)
CA/IComp
-ZECCA + V
(zosyn, erta, ceftaz, cefepime, azt), vanco
Vanco and Zosyn Rec
Vanco =< 5 mg/ml may be co-infused with Zosyn 3.375 g in 50 ml (or 4.5 g in 100 ml) through Y site
*NOT over 5+
History of Pseudomonas?
P. aeruginosa
Best Drugs
-Cefepime, Piperacillin (with or without Tazo)
-Cefto/Tazo (Zerbaxa)
-Cefta/Avib (Avycaz)
-Amikacin
-Cipro
Double Coverage
-If critically ill, neutropenic
-Add AG
