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SEPSIS

Humberto M. Guiot, MD, FACP


Infectious Disease
UPR School of Medicine

Objectives

To discuss the definition of sepsis


To differentiate between bacteremia, systemic
inflammatory response syndrome (SIRS), severe
sepsis, septic shock, and multi-organ
dysfunction syndrome
To establish strategies for management and
treatment of patients in sepsis

Vignette

A 69-year-old is brought to the emergency by his son


because of hypoactivity and drowsiness.
On physical examination, temperature is 40.1C, heart
rate is 132 bpm, respiratory rate is 32/min, and blood
pressure is 76/34 mmHg. The patient looks critically ill
and lethargic. Pulse oxymetry reveals an oxygen
saturation of 78%.

Q:

What is the
differential diagnosis?

Definitions

SIRS systemic inflammatory response syndrome to a


variety of severe clinical insults, most commonly
infectious, but also non infectious

pancreatitis, ischemia, multiple trauma, and tissue injury,


hemorrhagic shock, immune-mediated organ injury, and
exogenous administration of inflammatory mediators (tumor
necrosis factor or other cytokines).

2 or more of the following:

T > 38 C or <36 C
HR > 90 beats/min
RR > 20 breaths/min or pCO2 < 32 mmHg
WBC >12,000 cells/mm3, <4,000 cells/mm3, or >10% bands

Definitions

Sepsis SIRS to an infection.


Severe sepsis Sepsis associated to an organ
dysfunction, perfusion abnormalities (lactic acidosis,
oliguria, AMS), or hypotension (systolic BP <90
mmHg).
Septic shock Sepsis and hypotension despite adequate
fluid resuscitation.
MODS (multiorgan dysfunction syndrome) Altered
organ function in an acutely ill patient.
Bacteremia presence of viable bacteria in the blood

Vignette

The patient is immediately intubated and placed on


mechanical ventilation with 100% oxygen. Lungs show
bilateral fine expiratory ronchi. The extremities are cold
and clammy with evidence of cyanosis.
The patient has a history of type-2 diabetes mellitus and
benign prostatic hypertrophy. According to the son, he
was recently complaining of urinary hesitance, dribbling,
and suprapubic abdominal pain.
Immediate fluid challenge with 2L of 0.9% saline
solution is started
After 30 minutes, blood pressure is 82/50 mmHg

Vignette

CBC:

ABGs:

WBC 23,000 cells/mcL


Hct 17.2 g/dL
PTL 80,000 cells/mcL
pH 7.180
pCO2 56.7 mmHg
pO2 67.8 mmHg
HCO3 13.2 mEq/L

Electrolytes:

BUN 98 mg/dL
Creat 5.4 mg/dL

Q:

What is the
precise diagnosis now?

Sepsis and Septic Shock

13th leading cause of death in U.S.


500,000 episodes each year
35% mortality
30-50% culture-positive blood

Factors Associated with


Highest Mortality

Respiratory > abdominal > urinary


Nosocomial infection
Hypotension, anuria
Isolation of enterococci or fungi
Gram-negative bacteremia
Body temperature lower than 38C
Age greater than 40
Underlying illness: cirrhosis or malignancy

Predisposing Underlying
Diseases

Heart disease-rheumatic or congenital


Splenectomy
Intraabdominal sepsis
Septic abortion or pelvic infection
Intravenous drug abuse
Immunocompromised

Most Common Etiologies


Gram-negative bacilli

E. coli
Klebsiella pneumonia
Proteus
Pseudomonas

Gram-positive cocci
Gram-negative anaerobes

Organisms Responsible for Septic


Shock in Relation to Host Factors
Asplenia

Cirrhosis

Alcoholism

Encapsulated organisms
Pneumococcus spp.,
Haemophilus influenzae,
Neisseria meningtidis,
Capnocytophagia
canimorsus Babesiosis
Vibrio, Yersinia, and
Salmonella spp., other
Gram-negative rods (GNRs),
encapsulated organisms
Klebsiella spp.,
pnemococcus

Diabetes

Steroids

Mucormycosis and Pseudomonas ssp.


(malignant external otitis), Escherichia
coli
Tuberculosis, fungi, herpes virus

Neutropenia

Enteric GNR, Pseudomonas,


Aspergillus, Candida, and Mucor spp.,
Staphylococcus aureus

T-cell
abnortmalities

Listeria, Salmonella, and Mycobacteria


spp., herpes virus group (herpes simplex
virus, cytomegalovirus, varicella zoster
virus)

Vignette
The patient persists on mechanical ventilation
with 100% FiO2.
No urine output has been reported.
V/S: BP: 88/56 mmHg; HR: 122/min; RR:
28/min; T: 34 degrees
A thermal blanket is placed and the nephrologist
is consulted

Q:

What is the most


appropriate next step?

Surviving Sepsis Campaign

International initiative:
To reduce mortality rate
To improve standards of care
To secure adequate funding

Initial Resuscitation

Begin as soon as the sepsis syndrome is recognized.


CVP 8-12 mmHg
Mean Arterial Pressure > 65 mmHg
Urine output >0.5mL/kg / hr
Central venous pressure venous oxygen saturation
>70%

If not achieved with fluid resuscitation (CVP 8-12 mm HG)


during first 6 hours, then transfuse PRBC (to achieve HCT >
30%) or admister vasopressors

Fluid Resuscitation

Natural or artificial colloids (Dextran, gelatin) or


crystalloids (NSS, D5W, Lactate)
No evidence to support one over the other
Resuscitation with crystalloids requires more fluid
(because Vd is much larger)

Fluid challenge (500 1000 cc over 30 min) in


patients with suspected hypovolemia

Vassopressors

When fluid resuscitation fails to restore BP and organ perfusion


To sustain life and maintain perfusion in life-threatening
hypotension even during fluid challenge
First choice vasopressor: norepinephrine and dopamine
(through central catheter)

Both are preferred over epinephrine


Norepinephrine is more potent than dopamine and may be more
effective

Vasopressin for refractory shock despite adequate resuscitation


and high dose conventional vasopressors

Inotropic Therapy

Dobutamine may be used to increase cardiac


output.
If used during low blood pressure, it should be
combined with vasopressor therapy

Vignette

V/S are now: BP: 92/61 mmHg; HR: 102/min; RR:


22/min; T: 36 degrees
B/C: positive for GNB in 2 hours
U/A: turbid urine with sediments. WBC are TNTC,
many bacteria, positive nitrites, positive leukoesterase
Abdominopelvic CT scan shows an enlarged prostate.
There is bilateral obstructive ureterolithiasis with
hydronephrosis and prominent perinephric fat stranding
suggestive of bilateral pyelonephritis.

Q: How should the


infection be treated?

PRIOR TO ANTIBIOTICS:
Diagnosis!!!

Cultures are to be obtained before antimicrobials are


started
At least 2 B/C (one peripherally and one through
central catheter)
Culture of other sites (CSF, urine, wounds, respiratory
secretions)
Imaging studies and sampling of likely sources of
infection should be performed, but some patients may
be too unstable.

Antibiotic Therapy

Started within 1 hour of recognition


One or more drugs with activity against the
most likely pathogens and that penetrate the
presumed source of sepsis
Guided by susceptibility pattern
Use of procalcitonin (or similar markers) to
assist clinicians in the discontinuation of
antibiotics
Re-assess after 48-72 hours with the aim of
narrowing spectrum

Antibiotic Therapy

Duration: 7-10 days and guided by clinical


response (longer courses in MRSA, some fungal
and viral infections in immunodeficiencies,
patients with slow clinical response, etc)
Combination therapy against Pseudomonas and
Acinetobacter and in neutropenic patients
Stop antibiotics if clinical syndrome is
determined not to be infectious

Antibiotic Therapy

Urosepsis

Intra-abdominal infection

(Piperacilllin/tazobactam, higher general


cephalosporin or carbapenem) aminoglycoside
(Piperacilllin/tazobactam, higher general
cephalosporin or carbapenem) aminoglycoside
metronidazole

Pneumonia

(Cefepime, meropenem or impinem) PLUS


(aminoglycoside or quinolones) (vancomycin or
linezolid)

Antibiotic Therapy

CNS infection

Skin infection

Vancomycin PLUS (ceftriaxone or cefotaxime or


cefepime or meropenem) ampicillin acyclovir
(linezolid or vancomycin)
(piperacillin/tazobactam or cephalosporins or
carbapenem)

Endocarditis

depending on organism

Source control

Evaluate the presence of a focus of infection amenable for


source control measures within 12 hours, if feasible

Source control with the least physiological effect

Percutaneous rather than surgical drainage, for example

Source control as soon as possible following initial resuscitation

Drainage of abscess
Debridement of infected necrotic tissue
Removal of infected device

GI perforation
Intestinal ischemia

Promptly remove infected central lines/intravascular devices

Vignette

The patient was administered meropenem and


gentamicin
On the following day, the patient undergoes
hemodialysis.
Urologic Surgeon performs a bilateral double-J catheter
placement

Q:

What other
strategies are
recommended in the
treatment of sepsis?

Corticosteroids

IV Hydrocortisone (200-300 mg/day) is recommended for 7 days in patients


with septic shock requiring vasopressors

Three or four divided doses or continuous infusion

Rationale: a trial showed shock reversal and reduction in mortality in patients


with relative adrenal insufficiency (post-adrenocorticotropic hormone cortisol
increase <9 mcg/dL)
ACTH test to identify responders (>9mcg/dL increase in cortisol). No
steroids for responders, as these patients do not have relative adrenal
insufficiency.
Taper steroids after resolution of shock
Other authorities taper doses of corticosteroids at the end of therapy
No high dose hydrocortisone (>300 mg/day)
No shock = no steroids
Dexamethasone does not interfere with ACTH test

Activated Protein C

Recombinant human activated protein C


(rhAPC or drotrecogin alfa, Xigris) was
recommended in patients at high risk of death
(APACHE II>25, sepsis-induced MOF, septic
shock, or sepsis-induced ARDS) with no
absolute contraindication (mostly related to
bleeding or risk of bleeding).
Withdrawn from the US Market on October
2011 due to failure to show survival benefit

Blood Product Administration

After initial resuscitation

PRBC transfusion for Hb < 7 g/dL to a target of 7-9 g/dL


Erythropoetin is not recommended as specific treatment of
anemia associated to severe sepsis
No FFP in the absence of bleeding or planned procedure
Antithrombin administration is not recommended for the
treatment of severe sepsis and shock
Platelet transfusion

<5,000
5,000-30,000 + risk of bleeding
>50,000 for surgery of invasive procedure

Glucose Control

BS < 150 mg/dL


Studies have used continuous infusion of insulin and
glucose
Best results with BS between 80-110 mg/dL
Glucose should be monitored frequently after
initiation of the protocol (every 30-60 mins) and on
a regular basis (every 4 hours) once BS has been
stabililized.

Nutrition protocol with preferential use of


enteric route

DVT Prophylaxis

Severe sepsis patients should receive prophylaxis


with low-dose unfractionated heparin or
LMWH.

In patients who have contraindications for heparin


use, mechanical prophylactic device (compression
stockings, intermittent compression device) is
recommended

Stress Ulcer Prophylaxis

Should be given to all patients with severe sepsis


H2 receptor blockers are more efficacious than
sucralfate

PPIs have not been assessed in a direct comparison


with H2 receptor antagonists

Vignette

72 hours after admission:

Vasopressors could be discontinued


Creat is now 1.5 mg/dL and dialysis is put on hold
FiO2 has been decreased to 40%
Final B/C and U/C report: MDS E. coli
WBC are 11,000 cells/mcL while PTL count is 140,000
cells/mcL

Q:

What is the most


appropriate next step?

Q:

What would be
done if the course had
been different?

Consideration for Limitation of Support

Advance care planning (communication of likely


outcomes and realistic goals) should be
discussed with patients and relatives.
Decisions for less aggressive support or
withdrawal of support may be in the patients
best interest.

References

Surviving Sepsis Campaign: International


Guidelines for the Management of Severe Sepsis
and Septic Shock. Crit Care Med. 2013; 41:
580-637.
Surviving Sepsis Campaign: Guidelines for the
Management of Severe Sepsis and Septic
Shock. Crit Care Med. 2004; 32: 858-873.
Gorbach SL. Infectious Diseases, 3rd edition.