2. What is Sepsis?
Sepsis = clinical syndrome with
physiologic, biologic, and biochemical
abnormalities caused by
adysregulated inflammatory
responseto infection.
44% will have organ dysfunction
5. Sepsis 3.0 guideline
Current definition using āquick SOFAā score
ā¢ RR >/= 22 /min
ā¢ Altered GCS
ā¢ Systolic blood pressure </= 100mmHg
Sepsis = Signs ofinfection+qSOFA>/= 2
Score >/= 2 is associated with poor outcome (3% vs 24%)
Note: Not sensitive in ICU (use SOFA score) and pregnant ladies
6. Septic shock
ā¢ MAP <=65 despite adequate fluid resuscitation
ā¢ Lactate>= 2mmol/L despite adequate fluid
Ie: Low blood pressure, high lactate. Not responding to fluids.
Needs ICU and inotropes.
Singer et al. JAMA. 2016;315(8):801-810
7. Putting it togetherā¦ Sepsis signs
Signs of poor perfusion (Usually MAP <65mmHg)
ā¢ Altered mental status
ā¢ Reduced urine output/ renal failure
ā¢ Usually 20% of cardiac output goes to kidney, so very sensitive to reduction in cardiac output
ā¢ Usual urine output > 0.5 ml/kg/hr
ā¢ Cold periphery (hands and feet)/ pallor/reduced capillary refill
ā¢ Hypotension
ā¢ Lactic acidosis
SIRS response
ā¢ Fever / hypothermia (worse)
ā¢ Respiratory distress
ā¢ Multiple organ dysfunction
ā¢ General toxic appearance
Other subtle signs of septicaemia (bacteraemia)
ā¢ Rigors (Think Gram negative bacteraemia, higher mortality as multiple fasterā¦ but influenza also can have rigorsā¦ need full
picture/good historyā¦.)
ā¢ Severe myalgia
Always take a step back
and evaluate the full
pictureā¦ is this consistent
with infection? Is this
person in shock?
8. Epidemiology
ā¢ Worldwide incidence 30 million cases / year
ā¢6 million deaths
ā¢How big is the problem in Timor-leste?
ā¢Many are premature death and preventable
ā¢ Incidence is rising ā old age, increasing and
multidrug-resistant infection
ā¢ Bacteria infection is the predominant cause of
sepsis
ā¢ Half of cases have no organism identified
15. What is more likely to yield a positive
blood culture?
1. Take blood culture at time of fever
2. Take blood culture 15-30minutes before fever
3. Take 10 ml of blood for culture in each bottles
4. Blood culture doesnāt work
Blood culture positivity was 50.6% (78/154) among patients with sepsis who did not receive antibiotics and only 27.7%
(112/405) in those who were already receiving antibiotics (p <0.001).
16. Principles of sepsis management
ā¢ Early diagnosis
ā¢ How sick is this patient? ā ABCD, Q-SOFA, lactate
ā¢ Resuscitate (IV fluid 30ml/kg, if more than 2L needed, think inotropes)
ā¢ Cultures ideally before antibiotics
ā¢ For patients in septic shock ļ Blood culture with new IV cannula (if not in shock, try to take from other sites,
manipulation of cannula can increase risk of infection in cannula)
ā¢ But donāt delay antibiotics if other cultures (eg lumbar puncture) are going to take a while to get
ā¢ Appropriate antibiotics
ā¢ The sicker the patient, the faster the antibiotics need to be (If shock, within 1 hour)
ā¢ Sicker patients generally justify broader antibiotics until you figure out what is going on
22. What Antibiotics to Use?
ā¢Therapeutic guidelines
ā¢Specific antibiotics to a system that is identified eg. Meningococcal meningitis
ā¢ Gram positive cover ā Skin, respiratory tract, IVDU, IVC/lines, HDx
ā¢ Gram negative cover ā Hospital acquired infection, urine, gut
ā¢ Anaerobic cover ā Gut, biliary, aspiration pneumonia
ā¢ Specific exposure
ā¢ Aquatic
ā¢ Zoonosis
ā¢ Animal bite
23. Canāt Source the Antibiotics?
ā¢ Tell/ask someone ā consultant, Infectious Diseases team, Pharmacist
ā¢ There are always alternatives
ā¢ What happens if we canāt get an IVC in?
ā¢ If patient is septic and canāt tolerate oralā establish other IV access with
ICU/anaesthetics help
ā¢ Some can be given IM eg. Ceftriaxone
ā¢ If stable ļ do we need IV antibiotics?
24. It is a balanceā¦
Septic shock: Time = lives saved
Appropriate antibiotics = lives saved
How to give appropriate antibiotics? Culturesā¦. While waiting for AST ļ Antibiogram and
therapeutic guidelines
Appropriate source control and resuscitation = lives saved
Simple infection: You can go narrow-spectrum and treat according to symptoms
25.
26.
27. So what can we do:
ā¢ Ensure right dose
ā¢ Children
ā¢ Eg. Ceftriaxone 1g OD for pneumonia but 2g BD needed for meningitis (Blood-brain-barrier)
ā¢ Adjusted to weight, kidney function and liver cirrhosis
ā¢ Ensure right frequency
ā¢ Cloxacillin IV 1g QID for cellulitis vs cloxacillin 2g Q4h for endocarditis
ā¢ Ensure right duration
ā¢ If line infection ļ may not need antibiotics if line removed immediately
ā¢ Cellulitis, pyelonephritis ā 7-10 days
ā¢ Abscess in liver, abdomen, kidney, lungs ā 3-4 weeks
ā¢ Endocarditis, acute bone/joint infection 6 weeks (depending on organism)
ā¢ Abscess in spine / vertebrodiscitis ā 12 weeks
ā¢ Encourage monitoring for toxicity ā Liver function, biochemistry, CBC, clinical
ā¢ Work as a multidisciplinary team
ā¢ Encourage use of guidelines
28. Remember
Resistant organisms do not cause more
severe illness than their sensitive
counterparts. Theonly reasonfor using
broader than usual therapy is when you
(and the patient) cannot afford to be
wrong.
If on appropriate antibiotics, the main
thing we need to do is to support patients
through their SIRS processā¦.
29. What happens if there is antibiotics
overuse?
Resistant
gene