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Bacterial sepsis refers to symptomatic bacteremia, with or without organ

dysfunction. Sepsis is commonly dened as the presence of infection in

conjunction with the systemic inammatory response syndrome (SIRS! se"ere

sepsis, as sepsis complicated by organ dysfunction! and septic shoc#, as sepsis$

induced acute circulatory failure characteri%ed by persistent arterial hypotension

despite ade&uate "olume resuscitation and not e'plained by other causes.

Essential update: CDC-recommended catheter-care procedure cuts

sepsis rate in dialysis

In a study of hemodialysis patients from )) facilities, a new catheter$care

procedure recommended by the *S +enters for isease +ontrol and -re"ention

(++ pro"ed to be more eecti"e than usual care in reducing bloodstream

infection ris# in hemodialysis./0, )1

-atients in the study, all of whom were undergoing hemodialysis with central

"enous catheters (+2+s, recei"ed either usual catheter care or treatment withthe newly recommended procedure, which in"ol"es e'it$site care incorporating

the use of )3 chlorhe'idine with 453 alcohol swab stic#s, as well as the use of

453 alcohol pads to scrub the hub of the catheter.

6ccording to the report, the ++$recommended procedure reduced the rate of

bloodstream infections and intra"enous (I2 antibiotic starts by )53.

Signs and symptoms

7he history and physical e'amination may suggest the li#ely source of the septic

process and thereby help determine the appropriate antimicrobial therapy.8eneral signs and symptoms may include the following9

:e"er, with or without sha#ing chills

Impaired mental status (in the setting of fe"er or hypoperfusion

Increased breathing rate due to respiratory al#alosis

;arm or cold s#in, depending on the ade&uacy of organ perfusion and

dilatation of the supercial "essels of the s#in

7he following factors suggest an I2 line infection9

6n infected central line site! peripheral "enous lines are almost ne"er

in"ol"ed, and arterial lines are rarely associated with bacteremia

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6bdominal pain > iuse pain (suggesting pancreatitis or generali%ed

peritonitis, right upper &uadrant (R*? tenderness (gallbladder etiology,

right lower &uadrant (R@? tenderness (appendicitis or +rohn disease, or

discrete left lower &uadrant (@@? tenderness (di"erticulitis

6bnormalities on rectal e'amination > @i"er disease, gallbladder disease, colon disease, abscess,

intestinal obstruction, and 8I instrumentation

8* tract > -yelonephritis, intra$ or perinephric abscess, renal calculi,

urinary tract obstruction, acute prostatitis or abscess, renal insuAciency,

and 8* instrumentation

-el"is > -eritonitis and pel"ic abscess

@ower respiratory tract > +ommunity$ac&uired pneumonia (with asplenia,

empyema, and lung abscess

2ascular system > Infected I2 line or prosthetic de"ice

=eart and cardiac "asculature > 6cute bacterial endocarditis and

myocardial or peri"al"ular ring abscess

See +linical -resentationfor more detail.

Diagnosis

@aboratory studies that may be considered include the following9

+omplete blood count (+B+ > *sually not helpful

http://emedicine.medscape.com/article/234587-clinicalhttp://emedicine.medscape.com/article/234587-clinical

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Bacterial cultures > Blood cultures at admission! culture of the catheter tip

(for suspected central I2 line sepsis! nasal cultures (potential mar#er of

RS6 ris#

Stained buy coat smears or 8ram staining of peripheral blood

*rine studies (8ram stain, urinalysis, and urine culture

-rocalcitonin le"els

Imaging modalities that may be helpful include the following9

+hest radiography (to rule out pneumonia and diagnose other causes of

pulmonary inltrates

6bdominal ultrasonography (for suspected biliary tract obstruction

6bdominal +7 or RI (for assessing a suspected nonbiliary intra$abdominalsource of infection or delineating intrarenal and e'trarenal pathology

7he following cardiac studies may be useful if acute myocardial infarction (I is

li#ely9

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6ppropriate antimicrobial therapy depends on ade&uate co"erage of the resident

ora of the organ system presumed to be the source of the septic process, as

follows9

I2 line infections > eropenem or cefepime plus additional co"erage for

staphylococci! if RS6 is pre"alent, addition of line%olid, "ancomycin, ordaptomycin! if coagulase$negati"e staphylococci are reco"ered, a"oidance

of "ancomycin if possible! line remo"al

Biliary tract infections > Imipenem, meropenem, or piperacillin

Intra$abdominal and pel"ic infections > Imipenem, meropenem,

monio'acin, piperacillin$ta%obactam, ampicillin$sulbactam, or tigecycline!

clindamycin or metronida%ole plus a%treonam, le"oo'acin, or an

aminoglycoside

*rosepsis > 6%treonam, le"oo'acin, a third$ or fourth$generationcephalosporin, or an aminoglycoside! for enterococci, ampicillin or

"ancomycin! for "ancomycin$resistant enterococcal urosepsis, line%olid or

daptomycin! for community$ac&uired urosepsis, le"oo'acin, a%treonam,

or an aminoglycoside plus ampicillin! for nosocomial urosepsis, piperacillin,

imipenem, or meropenem

Staphylococcal, pneumococcal, or meningococcal sepsis > Cafcillin, an

antistaphylococcal agent, a cephalosporin, a carbapenem, daptomycin, or

line%olid! penicillin 8 or a beta$lactam

Sepsis of un#nown origin > eropenem, imipenem, piperacillin$

ta%obactam, or tigecycline! metronida%ole plus either le"oo'acin,

a%treonam, cefepime, or ceftria'one