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

pseudosepsis

Within last two weeks, I have diagnosed and treated 3 H1N1 pneumonia with ARDS. One who is severely obese (BMI>60), one pregnant lady who just had LSCS due to fetal distress and then a student who presented as acute exacerbation of bronchial asthma eventhough the last attack was more than 15 years ago. I used fluid restriction strategy with frusemide to keep even balance, according to FACTT trial and ARDS net ventilation strategy but with initial PEEP of 14-16cmH2O.
I have noticed in one patient, the WCC rised to more than 30,000 but her cultures were all negative. Anyway, I'd changed all of her lines. Her condition was alway stable with only low grade fever.
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Pseudosepsis
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Conditions that mimic sepsis
Common disorders:
1. Diuretic induced hypovolemia
2. Acute GI hemorrhage
3. Acute PE
4. Acute MI
5. Acute (oedematous/necrotic) pancreatitis

Uncommon disorders:
1. Diabetic ketoacidosis
2. SLE flare
3. Relative adrenal insufficiency
4. Rectus sheath hematoma

Several conditions may present with acute abdominal pain accompanied by fever, leukocytosis with a left shift and hypotension mimicking intra-abdominal sepsis. Such patients may have SG catheter readings that are compatible with sepsis. These medical disorders include diabetic crisis in diabetic ketoacidosis, luetic crisis in patient with syphilis, right rectus syndrome in patients with EBV infectious mononucleosis, rectus sheath hematoma, acute porphyria, SLE flare involving the peritoneum, acalculous cholecystitis due to vasculitis, dissecting AAA, splenic rupture, and pseudoappendicitis due to yersinis enterocolitica or other organism. These medical mimics of acute intra abdominal sepsis are serious disorders, many of which have specific treatments.
The correct presumptive diagnosis is essential for effective therapy of sepsis as well as in the disorders mimicking sepsis.

neutropenic sepsis

It has been a while since I am back for good. Sadly to say that I deferred my clinical exam to next year. Everything happenned for a reason and I had a fruitful break from my daily life. Here I come, fresh and vibrant!!
I just feel like writing something, it is not an update..just to write something that I saw on my table. It is a brief overview of neutropenic sepsis.
Don't you know that about 80% of infections in the neutropenic patient arise from endegenous flora. Bacteria pathogens are the most commonly isolated, in particular:
E.Coli, Pseudomonas, staph aureus, coagulase neg staph, pneumonococcus and other streptococci, Enterococci, enterobacter, Klebsiella and clostridium.
Please remember other pathogens which are of significant important such as aspergillus, candida species and viruses (HSV, VZV,CMV)

Looking for source of infection and source control are the mainstay of management. Infectious focus could only identified in only 30% of patients, therefore a thorough, structured and careful clinical examination is required. Specific infections that must be looked for include mucositis, catheter related infection, pneumonia, skin lesions, perianal abscess, sinusitis, dental abscess and abdominal pathology. A full septic screen is required and this include CXR. There shouldn't be a delay in administering antibiotic or antimicrobial therapy.

Source control is critical. Removal of CVC is required whenever there are clinical signs of CRBSI or suspected organisms are cultured. In septic shock (with hypotension and organ failure), empirical removal of CVC is strongly indicated.

Antimicrobial therapy: Delay in antibiotic therapy is directly correlated with mortality. Empiric antibiotic therapy is indicated for all patients with neutrophil count less than 0.5 or temperature more than 38C. Initial therapy is usually betalactam with antipseudomonal activity. Vancomycin is added if the patient is in shock, MRSA colonised, or has clinical evidence of mucositis or a catheter related infection. Initial antifungal therapy is indicated for bone marrow transplant recipients and for other patients if the febrile neutropenia persists despite 5 days of broad spectrum antibiotic therapy.

G-CSF are generally used for critically ill patients with post chemotherapy neutropenia. G-CSF has been shown to reduce the duration of neutropenia but not influence mortality in a broad population of neutropenic patients, and evidence is lacking for ICU patients. Usually its used is considered for patients with organ failure.