Septic Work up/Fever and Bacteremia Lecture Powerpoint Flashcards
Systemic inflammatory response syndrome (SIRS)
Exaggerated inflammatory reaction with vasodilation, permability, leukocyte accumulation, and platelet aggregation either localized or widespread defined by 2 or more of the following (abnormal HR (required), RR, temp, or leukocyte count (required))
Sepsis
SIRS criteria + a source of infection suspected or proven
Severe sepsis
Sepsis plus organ dysfunction of one or more major systems
Septic shock
Severe sepsis plus persistent hypotension despite aggressive fluid resuscitation
Multiple organ dysfunction syndrome (MODS)
Sepsis plus progressive dysfunction of 2 or more organs or organ systems
Causes other than infection that can cause SIRS (3)
- trauma
- burns
- pancreatitis
SIRS criteria
Presence of 2+ and one must be either abnormal temp or leukocyte count
- core temp >38.5C or <36C
- tachycardia (age specific) or bradycardia if less than 1
- tachypnea (age specific)
- leukocyte count (high or low for age or >10% bands)
Leading cause of morbidity/mortality/healthcare costs in infants and children in US and 3 sources
Sepsis, typically pneumonia, influenza, UTI
vaccines have helped. Hib is huge worldwide but not in US cause of vaccine
Organ specific effects of sepsis***(6)
- hypotension 2nd to vasodilation (circulation)
- capillary permability resulting in pulmonary edema (lung)
- translocation of bacteria and endotoxin into systemic circulation, disruption of normal GI barrier function (GI tract)
- acute renal failure (kidney)
- altered mental status*** usually first symtpom (nervous system)
- DIC (hematology)
DIC
Disseminated intravascular coagulation, condition in whcih small bood clots develop thruout the blood stream blocking small vessels depleting platelets and clotting factors needed to control bleeding caused by excessive bleeding (excessive clotting followed by excessive bleeding)
Labs to determine DIC presence
- plasma D dimer elevated
- low or decreasing levels of fibrinogen (all consumed)
Risk factors for sepsis (4)
- serious injury
- chronic debilitating condition
- host immunosuppression
- indwelling catheter
Neonatal sepsis
Bacteremia plus systemic signs of infection in first 30 days of life causing signs and symptoms such as fever, irritability, abnormal temp, difficulty breathing, jaundice, vomiting
Pathogens involved in neonatal sepsis (3)
-GBS, e coli, S pneumoniae (not normally viruses, might have coinfection with bacteria)
The only way to treat against neonatal sepsis is to…
….test the mother and treat accordingly or not have a natural birth
Culture negative sepsis
Occurs if antibiotics are used before obtaining cultures
Physical findings of neonatal sepsis (6)
- “somethings not right”
- changes in urine output
- fever, cough
- Petechiae and purpura
- respiratory depression
- hypoglycemia
Who gets a septic workup?
Any infant with identifiable risk factors and or signs and symptoms concerning for sepsis
Septic work up history questions (7)
- immunization history
- maternal infections
- exposures
- recent infections and treatments
- travel history
- past history
- documentation of fever
Presence of papilledema and concern for meningitis, don’t get a ___, first do a ___
lumbar puncture, CT
Treatment delay while awaiting studies
Should NOT be delayed
Sepsis workup labs (13)
- CBC with diff
- lactate (degree of organ hypoperfusion)
- BMP
- rapid glucose
- hypocalcemia
- PT/INR/PTT
- ABG
- urinalysis
- fibrinogen and d dimer
- blood culture
- C reactive protein and procalcitonin (if high indicates severe bacterial infection if differential is heart disease)
- LP (check retina and fontanelles first)
- TORCH titers
Septic workup by age
Febrile neonates up to 90 days need full workup, febrile infants and children more directed
Sepsis treatment bundle (5)
Airway breathing Circulatoin IV fluids Empiric antibiotics IV or IO 2 ports
Antibiotic regimen for community acquired sepsis
- ampicillin and gentamicin maybe with HSV
- Vanco sub for ampicillin if MRSA
Antibiotic regimen for hospital acquired sepsis (hospitalized since birth)
- Gentamicin and vanco
- clindamycin and metranidazole for GI source
Fever of uknown origin (FUO)
Prolonged febrile illness without an established etiology despite thorough eval at least once a day for at least 8 days
Hyperpyrexia
Temp >106F
Familial mediterranean fever
Armenian and turkish populations that have genetic predisposition to recurring fevers
Most common cause of acute recurrent fevers
Certain types of viruses
Diagnostic tests to assess fever of unknnown origin (7)
- CBC with diff
- ESR
- blood culture
- UA and culture
- CXR
- TB test
- HIV
Benefits of fever (3)
- hinders growth and replication of pathogen
- kicks immune system into higher gear
- enhances phagocytosis
Should a fever be treated?
Depends on how patient is doing, if they are doing alright then can hold off but 3 months old with 102 or higher need workup, avoiding empirical treatment with antibiotics or anti-inflammatories as diagnostic measures, if goes above 106 then do need treatment with tylenol and ibuprofen to prevent severe complications
Single largest infectious cause of death <5 years old
pneumonia
Pathogen most responsible for bacterial pneumonia in all pediatric populations
Strep pneumoniae
Neonatal pneumonia 2 concerning pathogens
- group B strep
- e coli
Leading cause of pneumonia in the HIV infected baby
Pneumocystitis jiroveci
Atypical pneumonia 2 common pathogens
mycoplasma pneumoniae
chlamydia pneumoniae
Studies for pneumonia in pediatric patients (3)
- CBC
- CXR
- viral testing if necessary
