Clinical Approach to the Septic Patient

Diagnosis For both community and hospitalised patients presenting with sepsis:

1. Diagnose or rule out mimics of sepsis by history, physical examination and routine lab tests


2. Initiate medical therapy appropriate for disorders mimicking sepsis


3. If mimics of sepsis are ruled out determine site of septic focus in critically ill patients presenting with sepsis, distinguish colonisation from infection in isolates from urine, respiratory secretions and noninfected wounds


4. Treat infection and avoid treating colonizing organisms

Interventions

A. Antibiotic interventions

i. Select empiric monotherapy based on coverage of predictable pathogens determined by focus of infection

ii. Select antibiotic with low resistance potential

iii. Select antibiotic witn a good safety profile

B. Non antibiotic interventions

i. Administer aggressive and effective intravascular volume replacement

ii. If pressors are needed, give volume replacement before pressors

iii. Restore normothermia with heating blanket

iv. Surgical intervention if sepsis is related to intra-abdominal organ perforation or obstruction or abscess. For infected devices, remove the device.

It is of paramount important to give fluid therapy before giving vasopressors. If the hypovolemia is not corrected promptly the patient will progress to a refractory shock state. By then the tissue perfusion would not respond to vasopressor drugs, even the blood pressure and intravascular volume were to be restored and cardiac output would remain depressed. The resultant lactic acidosis further depresses the myocardium and worsens the hypotension. The common complications of prolonged shock are massive bleeding, DIC and MODS which are often fatal.

Questions:

1. List the likely pathogens in gram negative sepsis in a patient who has been on meropenem for a week?

a. stenotrophomonas

b. MDR acinetobacter or pseudomonas

2. List the factors which result in failure in resolution of sepsis despite antibiotic therapy

• 
  
  wrong antibiotic choice


• 
  
  delayed administration of antibiotics


• 
  
  Inadequate source control


• 
  
  Inadequate antimicrobial blood levels


• 
  
  Inadequate penetration of the antimicrobial to the targer site


• 
  
  antimicrobial neutralization or antagonism


• 
  
  superinfection or unsuspected secondary bacterial infection


• 
  
  nonbacterial infection


• 
  
  noninfectious source of illness