1. SIRS 2. sepsis 3. severe sepsis 4. septic shock

speed (HR): >90 infxn (temp): >100.4 (38) OR 20 s(c)ells: >12,000 OR <4,000 PCO2 < 32

Van Bockern - Sepsis Flashcards by Alice Richards

very basic pathology of sepsis

dysregulated inflammatory response to an infxn

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what type of bacteria are mc responsible for sepsis

gram positive

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4 steps of sepsis

SIRS
sepsis
severe sepsis
septic shock

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SIRS criteria

speed (HR): >90
infxn (temp): >100.4 (38) OR <96.8 (36)
rr: >20
s(c)ells: >12,000 OR <4,000
PCO2 < 32

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sepsis criteria

2 SIRS criteria
PLUS
confirmed OR suspected infxn

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severe sepsis criteria

sepsis
PLUS
hypotn: SBP < 90
AND
lactate > 4

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septic shock criteria

severe sepsis w. persistent sbp < 90 and lactate > 4 despite adequate fluid resuscitation

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new sepsis guidelines

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6 sepsis rf

advanced age
immunosuppression/steroid use/malnutrition
DM/CA/HIV/liver dz
recent abx/drug resistance
recent procedures or travel
etoh/drug use

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ddx for fever

sepsis
drug rxn
VTE
malignancy
rheumatological

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lab findings in sepsis

arterial hypoxemia
adrenal insufficiency or euthyroid sick syndrome INR
platelets: 4
INR: >1.5 OR aPTT > 60s
lactate: >2
procalcitonin: >2 sd above nl
WBC: >12,000 OR 140 mg/dL w. DM
CRP: >2 sd above nl

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-Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO.
-Vitals: temp 39.0, RR 15, HR 104, BP 90/70.
-On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention.
-Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.

what do you do next

this pt meets sepsis criteria and is hemodynamically unstable ->
-start IVF
-broad spectrum abx
-identify source
-blood cultures

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what broad spectrum abx are used pre cultures for sepsis

vanco
cefepime
metronidazole

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Pt is a 48 year old female with PMH of HIV who presented to the hospital with diarrhea for the last 5 days. She’s unable to tolerate anything PO.
-Vitals: temp 39.0, RR 15, HR 104, BP 90/70.
-On exam she had dry MM, tachy with a regular rhythm, tender abd, but no distention.
-Her labs are significant for an abnormal CBC with WBC at 19k. Abnormal BMP with cr of 2.1, Na 131, and K 3.0. ECG nml. UA nml.

what should be included in her sepsis work up

blood cultures BEFORE abx are started
CXR
UA
stool PCR
CD4/viral load
CT-abd

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culture shows salmonella
CT abd shows pancolitis and terminal ileitis
CD4 count is trending down

what is your assessment

sepsis (put worst dx first) 2/2 to:
salmonella enteritis w.
salmonella bacteremia

pt meets sepsis criteria w. temp, tachy, rr, and elevated WBC
stool PCR (+) salmonella, 1/2 blood cultures w. enterobacteriaceae suspected salmonella. CT w. new pancolitis and terminal ileitis

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culture shows salmonella
CT abd shows pancolitis and terminal ileitis
CD4 count is trending down

what is your plan

continue levofloxacin qd
repeat cultures
antiemetics, IVF, APAP
consult ID regarding CD4 count

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don’t forget to do what when you order abx

include stop date

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-81 y.o.femalewith h/o of CVA who was admitted by home health agency due to decreased PO intake and altered mental status found to have a UTI
-Vitals: 115/57, RR 17, HR 66, Pulse ox %100 on 3L
-Gen: Appears ill, Dry MM, No evidence of volume overload
-Labs: WBC 12.6, Macrocytic Anemia, Elevated Cr, Hyponatremia, elevated troponin
-ECG: No evidence of ischemia UA: Positive

does pt meet sepsis criteria

no
vitals are normal
she only meets WBC for sirs criteria

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what is your assessment

acute UTI w.
leukocytosis: urine culture w. enterococcus

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what is your plan

-switch from fosfomycin to vanco x 3 days given susceptibilities, allergies, qtc prolongation risk, and age
-IVF

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bacteria to consider when choosing abx for sepsis

gram positives
gram negatives
anaerobes
pseudomonas
MRSA
atypical PNA
special situations

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empiric abx coverage for sepsis covers (4)

pseudomonas
MRSA
anaerobes
special situations

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62 year old female admitted for a UTI being treated with CTX (ceftriaxone) develops hypotension overnight. You are called to bedside by the rapid response team.

What should you do?

IVF
switch CTX to pip-taz AND vanco
call ICU

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what abx cover pseudo

aztreonam
aminoglycosides
fluoroquinolones
carbapenems (never ertapenem)
cefepime
pip-taz

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2 abx janice usually uses a DH for pseudo coverage

pip-taz cefepime

what abx cover MRSA

tetracyclines sulfonamides (bactrim) lincosamide (clinda) glycoprotein (vanco) ceftaroline

why avoid clinda for MRSA

c.diff

why avoid bactrim for MRSA

hyperkalemia

what abx is commonly used for IV to PO transition for MRSA

doxy

what abx cover anaerobes

ampicillin-sulbactram (unasyn) pip-taz carbapenems metronidazole clinda

benefit of pip-taz for anaerobes

covers anaerobes and pseudo

what are the atypical bacteria (3)

chlamydophila pneumoniae legionella pneumophila mycoplasma pneumoniae

soc for atypical coverage

azithromycin

-71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever (mental status normal) -T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC what is the standard initial work up

-CBC -BMP +/- LFTs -Blood cultures -Lactate -UA -CXR

-71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever (mental status normal) -T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC work up shows (see pic) how do you decide if he should be inpatient or outpatient

CURB65 this pt: BUN > 19, SBP < 90 or DBP ≤ 60, Age > 65 3 rf = high risk for decompensation --> admit

4 respiratory viruses associated w. sepsis

influenza RSV rhinovirus COVID

t/f: you can determine viral vs bacterial etiology of sepsis based on pt presentation

when is typical flu season

nov-march (late fall to early spring)

tx for flu that decreases mortality, and length of stay

neuroaminidase inhibitor (osteltamivir)

osteltamivir is most effective for M&M reduction if given in the first __ of sx onset

48 hr

t/f: identifying if cause of pna is non-influenza virus is beneficial

f! does not impact abx use co-infxn w. bacteria is common pcr testing is espensive

fluvid (covid, flu, rsv) choose the option with covid, none of the others will affect treatment

when would you order blood cultures for pna patient

if the meet sepsis criteria

when might you order respiratory culture for pna patient (2)

-pt has had prior isolation of MRSA and/or pseudo in the past year -pt has been hospitalized AND received IV abx in the past 90 days

denver health protocol for ICU CAP abx if prior isolation of MRSA and/or pseudomonas from respiratory tract in the past year

ceftriaxone AND azithromycin +/-osteltamivir

denver health protocol for ICU CAP abx if no isolation of MRSA or pseudo from resp tract in the past year

cefepime AND azithromycin +/- oseltamivir

what are the two types of lactic acidosis

A: mc dt infxn --> -tissue hypoperfusion from sepsis hypovolemia -shock B causes: chronic disease and drugs -metformin -DKA -etoh -liver dz -HIV meds

type A

what type of bacteria do not significantly elevate pct

atypical

3 things outside of sepsis that can cause pct elevation

major stressors trauma surgery pancreatitis CKD

what might cause false negatives with pct elevation

drawn too early in infxn

when is pct useful in sepsis

to decide when to stop abx NOT useful in deciding when to start

are steroids SOC with CAP tx

nope! yes with covid

how many days of abx for initial management of CAP

5 days

do we need to cover for anaerobes if we are concerned for aspiration pna

nope, not anymore!

who gets extended spectrum abx for CAP

only pt's w. rf

-71 y/o M hx alcohol abuse, T2DM, CAD, p/w cough and fever coming to ER in December -T: 39.0 deg C HR: 124 BP: 82/40 RR: 24 SpO2: 84% RA; 92% 2L NC -Standard initial workup: CBC, BMP +/- LFTs, Blood cultures, Lactate, UA, CXR You give ceftriaxone, azithromycin, and a 30 cc/kg fluid bolus. After initial treatment, the serum lactate is 2.4, and BP is 102/80 --> type A lactic acidosis next... Your patient then starts to develop EtOH withdrawal He develops delirium tremens and is admitted to ICU and placed on a dexmedetomidine (Precedex) drip and scheduled lorazepam. On hospital day 4, he develops a temperature of 39 deg C, HR of 120, RR of 32, and BP of 98/50. WBCs trend up to 16k. Lactate is 3.4. CXR shows bibasilar infiltrates. COVID: negative. what do you suspect? what do you do?

suspect HAP -blood cultures x 2 prior to abx -respiratory culture prior to abx -influenza pcr if flu season -MICU (ICU) setting: urine strep pneumo and pct -empiric abx

limitation of non-invasive respiratory cultures (sputum or aspirate)

possible contamination or colonization

definition of HAP

pna developed 48 hours or more after hospital admit or while on ventilator

HAP abx selection

-empiric: cefepime 2g IV q 8 hr -VAP OR hx MRSA OR IV abx in past 90 days: cefepime + vanco -severely ill w. septic shock 2/2 pna: cefepime + vanco + amikacin

abx for aspiration pna

ceftriaxone PLUS azithromycin same as standard CAP tx don't need to cover for anaerobes anymore

when should you cover for anaerobes w. aspiration pna

if lung abscess or empyema

6 usual suspects of sepsis

pna bloodstream infxns intravascular catheter intra-abdominal infxn urosepsis surgical wounds

IVF resuscitation goals

-central venous pressure: 8-12 mmHg -mean arterial pressure: 65 mm Hg -urine output: 0.5 mL/kg1/hr1 -central venous (superior vena cava) or mixed venous SpO2: 70%

did the study Janice referenced show any difference in mortality in patients given balanced fluids vs NS vs slow vs fast infusion

nope! janice typically boluses for faster results

what might you consider if septic pt is not responding to fluids and/or pressors

septic heart -> order TTE remember that pressors can mask underlying HF

consideration for d.c of IVF for septic pt

d.c IVF long before pt d.c to make sure they are stable on their own

key points for IVF in sepsis

-reassess frequently -de-escelate and diurese early -balanced crystalloids for now

when should abx be started for sepsis

-w.in first hour of recognition of severe sepsis -after cultures

what is PICS

post intensive care syndrome: critical illness survivors suffer from worsening impairments in physical, cognitive, or behavioral domains

rf for PICS

-ICU length of stay > 24 hr -prolonged immobilization -severity of illness -advanced age -female -prior psych illness -prior cognitive impairment -lower socioeconomic status -exposure to steroids -hyperglycemia

what do you think when you see gram (-) and gram (+) bacteria on blood cultures in pt w. GI sx

fistula

what should you always order if your pt presents with a fever or spikes a fever during admit

blood cultures

what should always be on your GI ddx for sick pt

toothpick dx

inpt tx for COVID

-remdesivir IV -dexamethasone

what medication improves survival for hospitalized covid pt's

dexamethasone