sepsis

1. SEPSIS & RATIONAL USE OF
ANTIBIOTICS
SUPERVISOR: DR ALEX
PRESENTER:
VENOSHA
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
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 potentiallyhave high
risk of dying from infection
- Does not determine individual treatmentstrategies
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

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. Pathoge
n
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
PRINCIPLES OF MANAGEMENT:
• Optimise organ perfusion –fluid resuscitation/
vasopressor
• Eradicate infection
• Identify source  Source control  Antimicrobial
therapy
3 to give 3 to take
1. O2 (94-98% or 88 - 1. Blood cultures /other
92%) appropriate cultures
2. IV antibiotics 2. FBC, lactate
3. IV fluids 3. Assess urinary
output

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.

30. Urinary Tract
Infection

32. REFERENCE
• https://haiweb.org/wp-
content/uploads/2018/03/Report-Drivers-
of- Irrational-Use-of-Antibiotics.pdf