Urosepsis

Question 1

List some DDx. for a presentation of:

• flank pain
• dysuria
• temp 39
• tachycardia
• hypotension
• haematuria

Answer 1

PDx. sepsis secondary to UTI (likely pyelonephritis) 
DDx.
• Renal 
o	Uncomplicated UTI
o	Renal calculi 
o	Glomerulonephritis 
• GIT
o	Cholelithiasis 
o	Hepatitis
o	Diverticulitis
o	Intestinal obstruction 
o	Appendicitis 
o	Peritonitis 
• Respiratory
o	Pneumonia -> sepsis 
• Gynaecological
o	PID
o	Ectopic pregnancy

Question 2

Describe the different types of shock?

Answer 2

1) Distributive- severe peripheral vasodilation (e.g. sepsis, inflammation, neurogenic, anaphylactic)
2) Hypovolaemic- blood loss, fluid loss
2) Cardiogenic- cardiac pump failure (e.g. MI, HF, VF, valvular incompetence)
4) Obstructive- extra-cardiac pump failure (e.g. PE, tension pneumothorax, cardiac tamponade)

Question 3

Describe the primary survey of a pt with urosepsis?

Answer 3

A.	Airway: patent
B.	Breathing: give O2
C.	Ciruculation: haemodynamic monitoring (O2%, BP, HR, urine output, ECG, IV access), blood culture, ABG, fluid bolus, empirical Abx
D.	Diability: GCS, BSL
E.	Exposure: temp, wounds

Question 4

What investigations would you do?

Answer 4

• Diagnostic
o	Blood culture
o	ABG
o	Septic screen:
        -  Urine MCS
        - Stool MCS
        - Sputum MCS
        - CXR
        - LP (if neuro symptoms) 
• Lab 
o	FBC- infection, anaemia
o	ESR/CRP- inflammatory process
o	CMP
o	EUC- kidney function, electrolyte balance
o	LFT- liver function
o	Coag profile- DIC
• Imaging 
o	KUB Xray
o	CT pelvis 
o	Renal US
o	MRI- pyelonephritis

Question 5

What are the likely organisms? of urosepsis 


Answer 5

Common:
o	E. coli (GN)
o	Proteus mirabilis (GN)
o	Klebsiella (children) (GN)
Less common:
o	Enterococcus faecalis (GP) 
o	Pseudomonas auregonosa (nosocomial, DIC) (GN)
o	Enterobacteriae (GN)
o	Staph saprophyticus (young women) (GP)
o	Staph aureus (GP)

Question 6

What is inside an anaerobe and aerobe tube? 


Answer 6

Both:
o Nutrient broths- promote bacterial growth
• Growth factors (soybean, casein broth, yeast extract, sucrose bicarbs)
o Sodium polyanetholesulfate (SPS) resin- inactivate antibiotics
o Anticoagulant- neutralise bacteriocidal action of blood

Anerobic bottle:
o Low O2
o Nutrient subsidies (vit K, haemin)- aid anaerobic growth
o Reducing agent (1% glucose)
o Thioglycolate- consumes O2 -> aids anaerobic growth

Question 7

How would you treat this gram-negative sepsis?

Answer 7

Amoxicillin and gentamycin
o Commonly caused by enteric GN organisms- E. coli, Proteus mirabilis
- coverage: Gentamicin (aminoglycoside Abx)
o Possible GP organisms- enterococcus faecalis and staph saprophyticus
- coverage: Amoxicillin (broad sprectrum penicillin)

• If renal impairment: replace Gentamicin with Ceftriaxone
• If MDRO: Meropenem (Carbapenem)
• If mild pyelonephritis: Cefazolin (1st generation Cephalosporin)

Question 8

Describe the MA and SE of gentamicin?

Answer 8

Gentamicin (aminoglycoside antibiotic)
o MA: irreversibly binding ribosomal subunit 30S -> inhibits mRNA transcription -> prevents protein synthesis
o Spectrum: broad GN (not enterococci, strep cocci, anaerobes)
o SE: ototoxicity, nephrotoxicity, vestibular toxicity, neuromuscular blockade, narrow therapeutic index
o Monitor: renal function

Question 9

Describe the MA and spectrum of Amoxicillin?

Answer 9

Amoxicillin (broad spectrum penicillin, B lactamase)
o MA: inhibits peptidoglycan cross-linking -> inhibits cell wall synthesis -> accumulation of cell wall precursors -> autolysis -> cell death
o Spectrum: GP (includes enterococci, but not staph)

Question 10

What is the MA of Ceftriaxone?

Answer 10

Ceftriaxone (3rd generation Cephalosporin)

• MA: inhbit peptidpglycan crosslinking -> inhibits cell wall synthesis

Question 11

What is the MA of Meropenem?

Answer 11

Meropenem (Carbapenem)

- MA: inhibit cell wall synthesis