Low Rate Call Girls Pune Esha 9907093804 Short 1500 Night 6000 Best call girl...
Sepsis and rational use of abx
1. SEPSIS & RATIONAL USE OF ANTIBIOTICS
SUPERVISOR: DR SHAHIDAN
PRESENTER:
AFIQI FIKRI
2. • Sepsis is a spectrum disorders that occurs in cascading process.
• The American College of Chest Physicians (ACCP) and the
Society of Critical Care Medicine (SCCM) have defined sepsis as
confirmed or suspected infection in the presence of the
systemic inflammatory response syndrome (SIRS)
Sepsis is defined as
Life threatening
Organ dysfunction
Caused by dysregulated host response
To infection
DEFINITION
3. CMS Sepsis 1 Definitons Sepsis 3 Definitions
Sepsis – 2 SIRS criteria + suspected infection
SIRS Criteria
• Temp >101F / >38°C
• Temp < 96.8F / <36°C
• HR > 90 beats/min
• RR > 20 breaths/min
• WBC >12x10 cells/mm3
• WBC <4x10 cells/mm3
• >10% bandemia
Sepsis – suspected/documented infection + increase in
SOFA score of at least 2 from baseline
Severe Sepsis – sepsis + ≥1 variables of organ
dysfunction
• SBP <90mmHg
• MAP <70mmHg
• SBP decrease >40mmHg from known baseline
• SCr >2.0 mg/dL
• Urine output <0.5ml/kg/hr for >2 hr
• Bilirubin >2.0mg/dL
• Plt <100000/mm3
• INR >1.5 or PTT >60s
• Altered mental status
• Lactate >2mmol/L
Septic Shock – Severe sepsis + hypoperfusion despite
adequate fluid resuscitation or lactate >4mmol/L
Septic Shock – Sepsis + need for vasopressor and lactate
>2mmol/L despite adequate fluid resuscitation
Sequential Organ Failure Assesment (SOFA)
- AN ORGAN DYSFUNCTION SCORE
- Not diagnostic of sepsis nor does it identify those whose
organ dysfunction is truly due to infection but rather helps
- identify patients who have potentially have high risk of
dying from infection
- Does not determine individual treatment strategies
4. • Altered mental status – GCS score <15
• Systolic blood pressure (SBP) ≤100 mmHg
• Respiratory Rate ≥22 breaths/min
Suggest to identify patients with suspected infection who are likely to develop sepsis or septic
shock ( easy to perform by clinical examination )
Once patients meet at least 2 qSOFA criteria , organ dysfunction should be assessed using the
SOFA score
qSOFA
5.
6.
7.
8. Pathogen
Localized infection – activation of host defense mechanisms
influx of activated neutrophils and monocytes , release of inflammatory
mediators , local vasodilatation , increased endothelial permeability ,
and activation of coagulation pathways
Diffuse endothelial disruption , vascular permeability , vasodilatation ,
and thrombosis of end organ capillaries
Endothelial damage – further activate inflammatory and coagulation
cascades
Further endothelial and end organ damage
PATHOPHYSIOLOGY
9. • Extremes of age ( <10 years and >70 years )
• Primary diseases ( eg Liver cirrhosis , alcoholism , diabetes
mellitus , cardiopulmonary diseases , solid malignancy , and
hematological malignancy )
• Immunosuppression
• Major surgery , trauma , burns
• Invasive procedures
• Previous antibiotic treatment
• Prolonged hospitalization
• Underlying genetic susceptibility
• Other factors ( eg childbirth , abortion , and malnutrition )
Risk Factors
15. SEPSIS 6 IN 1ST HOUR
3 to give 3 to take
1. O2 (94-98% or 88 -
92%)
1. Blood cultures /other
appropriate cultures
2. IV antibiotics 2. FBC, lactate
3. IV fluids 3. Assess urinary output
PRINCIPLES OF MANAGEMENT:
• Optimise organ perfusion –fluid resuscitation/ vasopressor
• Eradicate infection
• Identify source Source control Antimicrobial therapy
16. • Resucitation should be titrated to clinical end
points such as vital signs, skin perfusion, urine
output (at least 0.5-1 ml/kg/hour) and oxygenation.
• Fluid resuscitation is the mainstay of
hemodynamic support in septic shock; only in
those not responsive to aggressive fluid challenge
or showing signs of pulmonary or cardiovascular
compromise, should vasopressors be added.
• Guidelines recommend at least a 30-ml/kg bolus
of crystalloid fluid as the initial resuscitation
(rhodes 2017)
FLUID RESUSCITATION
17. • Vasopressor may be added if there is no response to fluid challenge
• Noradrenaline is the agent of choice in septic shock, starting at 1 mcg/kg/min.
• A targeted MAP of 65 mm/Hg within the first hour is recommended
if MAP is not maintained at 65 mm hg or greater with norepinephrine alone or if the
norepinephrine dose needs to be decreased, either vasopressin (up to 0.03
unit/minute) or epinephrine can be added to norepinephrine (rhodes 2017)
• High-dose (greater than 0.03 unit/minute) vasopressin is not recommended in
patients with septic shock because it may cause significant ischemia, especially in
myocardium and bowel through significant vasoconstriction (holmes 2008)
• Dopamine is recommended as an alternative vasopressor to norepinephrine only in
patients with a low risk of tachyarrhythmias and absolute or relative bradycardia.
Low-dose dopamine drip is not recommended for renal protection.
VASOPRESSOR THERAPY
18. • Empiric, broad-spectrum intravenous antimicrobials should be
initiated as soon as possible after recognition, ideally after collection
of blood cultures and other cultures, and within 1 hour for both
sepsis and septic shock according to the current guidelines with
moderate evidence (Levy 2018).
• The SSC guidelines advocate broad-spectrum intravenous
antibiotics within the first hour of identifying sepsis and septic shock.
although the literature has shown the benefits of administering
appropriate antimicrobial therapy as quickly as possible in sepsis,
this still represents a logistical obstacle in most institutions (Rhodes
2017).
• In patients with a severe inflammatory state of noninfectious origin,
prophylactic systemic antimicrobials are not recommended.
EMPIRICAL TREATMENT
21. WHAT ARE ANTIBIOTICS?
• An antibiotic is a type of antimicrobial substance active against bacteria
and is the most important type of antibacterial agent for fighting bacterial
infections.
– Any substance that inhibit growth and replication of a bacterium or
kills it outright can be called as an antibiotic
• Rational use is extremely important as injudicious use can adversely affect
the patient, cause emergence of drug resistance and increase cost of
health care
• The term antimicrobials is accepted as a broader definition and includes
medicines used for
– Bacterial infections
– Viral infections
– Fungal infections
– Parasitic infections
22. • Bactericidal – Kill bacteria (tend to be used in
combination with one another)
• Bacteriostatic – Prevent bacteria’s
reproduction (tend to be used on its own)
23. Criteria for choosing an antibiotics:
• EFFICACY – narrow spectrum or broad spectrum.
– The spectrum of the antibiotic selected by the
clinician
should be the narrowest to cover known or likely
pathogens
– However, in scenarios where the causative agent is
not known and a delay in initiating therapy would
be life-threatening or risk serious morbidity, broad
spectrum antibiotics, based on the likelihood of
the pathogen(s), should be prescribed
24. • Monotherapy or combination therapy
– Use a single agent wherever possible in antibiotic treatment.
– However, there are situations when the use of an antibiotic
combination is desirable:
To achieve synergistic
effect against infection
Shortens the course of
the antibiotic therapy
When critically ill
patients require empiric
therapy before
bacteriological
diagnosis
To extend antibiotics
spectrum during
polymicrobial infections
To prevent the
development of
bacterial resistance
with long term therapy
25. DOSAGE, ROUTE OF ADMINISTRATION AND DURATION
• The clinician should consider pharmacokinetic and pharmacodynamic factors in
determining the drug dose.
• The dosage should be high enough to ensure efficacy and minimize the risk of
resistance
selection, and low enough to minimize the risk of dose related toxicity
• The clinician should ensure the most appropriate route of administration in
antibiotic treatment. Oral/enteral route of administration should be preferred in
patients with mild-to-moderate infections
• Clinicians should reserve intravenous antibiotics for severe infection or for certain
sites such as the CSF, bacteraemia, endocarditis and bone & joint infections
• Antibiotic treatment should generally be continued for a maximum of 5 days or a
shorter period if this is clinically appropriate; however, some specific conditions
require a longer course of therapy (viz. endocarditis, osteomyelitis etc
26. • Allergy or intolerance - Clinicians should routinely
obtain an evaluation of history of antibiotic allergy or
intolerance.
• Recent antibiotic use - Eliciting a history of
exposure to antimicrobial agents in the recent past
(approximately 3 months) can also help the clinician
in selecting an antimicrobial therapy. Because the
causative microorganism for a current episode of
infection emerged under the selective pressure of a
recently used antimicrobial agent, it is likely to
be resistant to that drug and/or drug class, and an
alternative agent should be used.
Sequential Organ FQuickSOFA was developed as tool to gauge severity of sepsis as part of the Sepsis-3 consensus and aimed to identify patients, primarily outside the ICU with suspected infection who are likely to develop complications of sepsis
They however do not define sepsis
Suggest to identify patients with suspected infection who are likely to develop sepsis or septic shock ( easy to perform by clinical examination )
ailure Assessment
Prognostic factors in sepsis
Host response to infection – failure to develop febrile response/ leucopenia
Underlying disease
Age
Site of infection
Microorganism
Antimicrobial therapy
