Sepsis and rational use of abx
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The document discusses sepsis and rational use of antibiotics. It defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. It outlines the definitions of sepsis, severe sepsis, and septic shock according to different criteria. It also discusses the pathophysiology, risk factors, common causes, signs and symptoms, and principles of management for sepsis which include early recognition, source control, and appropriate antibiotic therapy and fluid resuscitation. The document emphasizes the importance of rational antibiotic use by considering efficacy, dosage, route of administration, duration, history of allergy or intolerance, and recent antibiotic exposure.
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
- 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
- 10. Causes of sepsis
- 11. Lower Respiratory Tract Infections Streptococcus pneumoniae , Klebsiella pneumoniae , E.Coli , Legionella species , Haemophilus species , Staphylococcus aureus , Pseudomonas species , Anaerobes , Gram negative bacteria , Fungi Abdominal and GI Tract Infections E.Coli , Enterococcus species , Bacteroides fragilis , Acinetobacter species , Pseudomonas species , Enterobacter species , Salmonella species , Klebsieela species , Anaerobes Urinary Tract Infections E.Coli , Proteus species , Klebsiella species , Pseudomonas species , Enterobacter species , Serratia species , Enterococcus species , Candida species Male and Female reproductive systems Neisseria gonorrhoeae , Gram negative bacteria , Streptococci , Anaerobes Soft Tissue Infections S aureus , Staphylococcus epidermidis , Streptococci , Clostridium species , Gram negative bacteria , Anaerobes , Fungus Common Pathogen
- 12. Symptoms • Fever ( usually >38 C ) • Confusion • Anxiety • Difficulty breathing • Fatigue and malaise • Nausea and vomiting • Hyperventilation with metabolic alkalosis Signs • Altered mental status • Pallor or greyish or mottled skin • Cool skin , cool extremities , and delayed capillary refill • Decreased urine output • Cyanosis • Petechiae or purpura • Tachycardia • Narrow pulse pressure • Tachypnea Clinical Features
- 13. Management of sepsis: -Recognition, Resuscitation, Referral-
- 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
- 20. Rational use of antibiotic
- 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.
Editor's Notes
- #4: qSOFA = Sepsis Related Organ Failure Assessement
- #5: 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
- #16: Prognostic factors in sepsis Host response to infection – failure to develop febrile response/ leucopenia Underlying disease Age Site of infection Microorganism Antimicrobial therapy