IM

1. Sepsis

2. What is Sepsis?
Sepsis = clinical syndrome with
physiologic, biologic, and biochemical
abnormalities caused by
adysregulated inflammatory
responseto infection.
44% will have organ dysfunction

3. Sepsis continuum
Simple Infection
Systemic inflammatory response
syndrome (may occur in non-
infectious diseases as well)

4. SIRS response
and infection

5. Sepsis 3.0 guideline
Current definition using “quick SOFA” score
• RR >/= 22 /min
• Altered GCS
• Systolic blood pressure </= 100mmHg
Sepsis = Signs ofinfection+qSOFA>/= 2
Score >/= 2 is associated with poor outcome (3% vs 24%)
Note: Not sensitive in ICU (use SOFA score) and pregnant ladies

6. Septic shock
• MAP <=65 despite adequate fluid resuscitation
• Lactate>= 2mmol/L despite adequate fluid
Ie: Low blood pressure, high lactate. Not responding to fluids.
Needs ICU and inotropes.
Singer et al. JAMA. 2016;315(8):801-810

7. Putting it together… Sepsis signs
Signs of poor perfusion (Usually MAP <65mmHg)
• Altered mental status
• Reduced urine output/ renal failure
• Usually 20% of cardiac output goes to kidney, so very sensitive to reduction in cardiac output
• Usual urine output > 0.5 ml/kg/hr
• Cold periphery (hands and feet)/ pallor/reduced capillary refill
• Hypotension
• Lactic acidosis
SIRS response
• Fever / hypothermia (worse)
• Respiratory distress
• Multiple organ dysfunction
• General toxic appearance
Other subtle signs of septicaemia (bacteraemia)
• Rigors (Think Gram negative bacteraemia, higher mortality as multiple faster… but influenza also can have rigors… need full
picture/good history….)
• Severe myalgia
Always take a step back
and evaluate the full
picture… is this consistent
with infection? Is this
person in shock?

8. Epidemiology
• Worldwide incidence 30 million cases / year
•6 million deaths
•How big is the problem in Timor-leste?
•Many are premature death and preventable
• Incidence is rising – old age, increasing and
multidrug-resistant infection
• Bacteria infection is the predominant cause of
sepsis
• Half of cases have no organism identified

9. Risk Factors for Sepsis / Septic Shock
•Bacteraemia
• Advanced age >65yo
• Immunosuppression
• Diabetes, cancer, renal failure, liver failure, AIDS, splenectomy / asplenia, chemotherapy / steroids /
immunosuppressant
• Obesity
• Community acquired pneumonia
• Previous hospitalisation
• Genetics

10. What are the sources of sepsis
• Brain – meningitis, encephalitis
• Upper respiratory tract
• Lungs – pneumonia
• Heart – infective endocarditis
• Skin – cellulitis, wound, ulcer, abscess
• GI tract
• Intra-abdominal
• Urinary tract
• Bones and joints
• Systemic – eg meningococcal

11. Diagnosis
• History
• Examination
• Q-SOFA and ?shock
• RR >/= 22 /min
• Altered GCS
• SBP </= 100mmHg
• Basic bloods and cultures
• If unclear – “Septic screen”
• Blood culture x 3 sets – 2 sets within 1hour then repeat if febrile or at 24 hours
• Urine culture
• Sputum culture
• Chest X-ray

12. History - ICTOADS
• Immunocompromised state/ immunisations eg. Splenectomy and encapsulated organisms
(Haemophilus influenza, meningococcus, streptococcal pneumoniae), measles vaccine vs
vaccine-strain measles
• Contacts eg. Influenza / COVID 19
• Travel eg. Malaria, malaria, malaria… +/- typhoid fever
• Occupation eg. Rice paddy worker/Pig hunter and leptospirosis, HCW and COVID-19
• Animals eg. Birthing of cats/animals and Q fever
• Drugs eg. IVDU – skin organisms, candidaemia
• Specific exposure, Sex eg. HIV/STI, spelunking and leptospirosis,
vibrio/shewanella/chromobacterium violaceum/aeromonas and Water exposure

13. Examination
• Skin: rashes, wounds, ulcers
• Neck stiffness, photophobia - meningitis
• Auscultate lungs – effusion/empyema, pneumonia
• Heart sounds – murmurs – infective endocarditis
• Abdomen
• Lines/cannulas

14. Investigations
depending on
source of sepsis

15. What is more likely to yield a positive
blood culture?
1. Take blood culture at time of fever
2. Take blood culture 15-30minutes before fever
3. Take 10 ml of blood for culture in each bottles
4. Blood culture doesn’t work
Blood culture positivity was 50.6% (78/154) among patients with sepsis who did not receive antibiotics and only 27.7%
(112/405) in those who were already receiving antibiotics (p <0.001).

16. Principles of sepsis management
• Early diagnosis
• How sick is this patient? – ABCD, Q-SOFA, lactate
• Resuscitate (IV fluid 30ml/kg, if more than 2L needed, think inotropes)
• Cultures ideally before antibiotics
• For patients in septic shock  Blood culture with new IV cannula (if not in shock, try to take from other sites,
manipulation of cannula can increase risk of infection in cannula)
• But don’t delay antibiotics if other cultures (eg lumbar puncture) are going to take a while to get
• Appropriate antibiotics
• The sicker the patient, the faster the antibiotics need to be (If shock, within 1 hour)
• Sicker patients generally justify broader antibiotics until you figure out what is going on

17. Timing of Antibiotics
Kumar et al, 2006

18. Principles of sepsis management
• Directed investigations – Cultures, CXR, CT
• Consider source control
• Eg Drain abscesses, wash-out joints, surgery for intra-abdominal cause, remove infected line

19. Important of
“source control”
eg. Necrotising
fasciitis

20. Surgical source control for abdominal
infection eg. GI perforation

21. Delayed cholecystectomy

22. What Antibiotics to Use?
•Therapeutic guidelines
•Specific antibiotics to a system that is identified eg. Meningococcal meningitis
• Gram positive cover – Skin, respiratory tract, IVDU, IVC/lines, HDx
• Gram negative cover – Hospital acquired infection, urine, gut
• Anaerobic cover – Gut, biliary, aspiration pneumonia
• Specific exposure
• Aquatic
• Zoonosis
• Animal bite

23. Can’t Source the Antibiotics?
• Tell/ask someone – consultant, Infectious Diseases team, Pharmacist
• There are always alternatives
• What happens if we can’t get an IVC in?
• If patient is septic and can’t tolerate oral– establish other IV access with
ICU/anaesthetics help
• Some can be given IM eg. Ceftriaxone
• If stable  do we need IV antibiotics?

24. It is a balance…
Septic shock: Time = lives saved
Appropriate antibiotics = lives saved
How to give appropriate antibiotics? Cultures…. While waiting for AST Antibiogram and
therapeutic guidelines
Appropriate source control and resuscitation = lives saved
Simple infection: You can go narrow-spectrum and treat according to symptoms

27. So what can we do:
• Ensure right dose
• Children
• Eg. Ceftriaxone 1g OD for pneumonia but 2g BD needed for meningitis (Blood-brain-barrier)
• Adjusted to weight, kidney function and liver cirrhosis
• Ensure right frequency
• Cloxacillin IV 1g QID for cellulitis vs cloxacillin 2g Q4h for endocarditis
• Ensure right duration
• If line infection  may not need antibiotics if line removed immediately
• Cellulitis, pyelonephritis – 7-10 days
• Abscess in liver, abdomen, kidney, lungs – 3-4 weeks
• Endocarditis, acute bone/joint infection 6 weeks (depending on organism)
• Abscess in spine / vertebrodiscitis – 12 weeks
• Encourage monitoring for toxicity – Liver function, biochemistry, CBC, clinical
• Work as a multidisciplinary team
• Encourage use of guidelines

28. Remember
Resistant organisms do not cause more
severe illness than their sensitive
counterparts. Theonly reasonfor using
broader than usual therapy is when you
(and the patient) cannot afford to be
wrong.
If on appropriate antibiotics, the main
thing we need to do is to support patients
through their SIRS process….

29. What happens if there is antibiotics
overuse?
Resistant
gene

30. Obrigada