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Gram Negative Bacteraemia
Dr Jasraj Singh
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Overview
• Microbiology Review• Gram Classification
• Sesis et al
• MODS! SO"# score
• $here! what! whom%
• GN statistics
• Sesis care b&n'le
• #ntibiotics• Sharings
• (a)e home message
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Gram Stain
Gram * with thic)er cellwall able to absorb stain+
aear violet,
Gram - 'o not retain
crystal violet at staining,
Re.&ire co&nterstain,
#tyicals/
Mycobact! (reanoma!
Chlamy'ia! Ric)ettsia
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G * vS G -
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Str&ct&ral 0mortance
• G- have 12S o&ter membrane 3 Release 4n'oto5ins in
bacteraemia+
4n'oto5ic shoc)
3 2rotection vS antibiotics that 'estroy cell wall!
i,e, 2enicillins
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Gram Negative brea)'own
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Gram 2ositive brea)'own
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Sesis et al,
6, S0RS7, Sesis
8, Severe Sesis
9, Setic Shoc)
0nfection / #n inflammatory resonse to the resence
ofmicroorganisms or the invasion of normally sterile hosttiss&e
by these organisms,
Bacteraemia/ (he resence of viable bacteria in the bloo',
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S0RS
• Systemic 0nflammatory Resonse Syn'rome! toa variety of several
clinical ins<s,
• 7 or more of the following criteria/
3 (em/ :8;
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Definitions
• Sesis 3 nown or s§e' infection 3 7 or more
S0RS criteria
• Severe Sesis 3 Sesis with sesis-in'&ce' organ
'ysf&nction
3 MODS
• Setic shoc) 3 Severe sesis * hyotension 'esite
a'e.&ate fl&i'
res&s or re.&iring 0notroic s&ort to maintain B2
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MODS
• M<ile Organ Dysf&nction Syn'rome
3 progressive, reversible fail&re of 7 or
more organ systems
3 homeostasis can
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$hat goes first%
• $hat goes first%
3 Resiratory "ail&re/ 0nitial 7hrs
3 1iver "ail&re/ H- 'ays
• ?yo5emia ca&sing heatocell&lar necrosis * hematologic
abnormalities
• 4ncehaloathy+ increase' nitrogen loa'
3 G0( Blee'/ 6A-6H 'ays
• #ci'-base 'ist&rbances! coag&lation
abnormalities
3 i'ney "ail&re/ 66-6 'ays
• Iasoressor 'een'ent! olig&rican&ric! 1actic
aci'osis,
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SO"# score
• Se.&ential Organ "ail&re #ssessment+ 0Cscore,
• 2re'ictor of mortality
• Se.&ential assessment
• Score = @/ re'ictive mortality K 88L
• Score :66/ re'ictive mortality K @HL
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$here
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$hat
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$ho
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$ho
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Gram Negative Sesis
• Most common ca&se of bloo'streaminfections in the S! 7AA;
8
• 98L more common in Setic Shoc)6
3 ?a' higher levels of CR2 an' 01->• ?igher mortality+
9AL6
3 7;L G2! 88,8L Mi5e'
• Reson' better to anti-(N" theraies7
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Gram Negative Sesis
• ?ighly-resistant GN athogens 3 #cinetobacter s,
3 MDR 2, aer&ginosa
3Carbaenem resistant lebsiella s, 4,coliECR4F
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Management+ 4GD(
•4arly Recognition• Monitoring
• Res&scitation
• 2ressor s&ort
• So&rce control
• #ntibiotics
• #'j&vant theray/ Stress &lcer rohyla5is! DI(
rohyla5is! Se'ation! #nalgesia! Organrelacement
• 45erimental theray
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Sesis Care B&n'le8
•$ithin 8 ho&rs6, Meas&re lactate levels7, Obtain bloo'
c<&res rior to ab a'min
8, #'minister broa'-sec ab
9, 8Acc)g Crystalloi's for hyotension 1actate :9 mmol1
• $ithin > ho&rs
6, Iasoressors if hyotension 'esite fl&i' res&s+ M#2 :
>H
7, Remeas&re hy'ration stat&s
- Iitals! CR(! t&rgor! &rine o&t&t! CI2
8, Reeat 1actate
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#ntibiotics
•No single
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• 2res&me' GN sesis
3 #minoglycosi'e/ Gentamicin! #mi)acin
* 45t sectr&m Cehalosorin/ Cefota5! Ceftria5one
or with #ntise&'omonal/ Ceftai'ime! Cefoeraone ECefobi'F
• ?osital ac.&ire'
3 more commonly lebsiella than 2se&'omonas
3 e5ten'e' sec Cehalosorin
• 2res&me' 2se&'omonas infection
3 antise&'omonal enicillin/ (aosin E2ieracillin*
(aobactam
e5t sec Beta 1actam with Beta 1actamase inhibitorF
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• Resistance to Cehalosorins 2enicillins
3 0mienem ECarbaenem+ Beta 1actamF
* #minoglycosi'e
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Stewise antibiotic theray
6, GN coverage+ Cef&ro5ime7, : GN coverage! e5cet
2se&'omonas
3 Ceftria5one! Ceftai'ime! Cefota5ime
8, :GN coverage! with 2se&'omonas 3 Cefeime
9, ::GN coverage! es 4,colileb2se&'o 3 Gentamycin!
#mi)acin
H, ::GN coverage * G2Ee5cet MRS#FPBroa' secQ 3 Meroenem!
0mienem! 4rtaenem
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Sharings
• 2rocalcitonin 3 New! secific infectio&s EbacterialF
inflammatory mar)er
3 ;HL sensitivity! @8L secificity vS 01-6>;! (N"-alha!
CR2
3 0ncreases 79-9; hrs before CR2
• "l&oro.&inolones 3 inhibit early fract&re
healing thro&gh to5ic effects on
chon'rocytes
3 increase' rates of ten'initis! with secial re'ilection
for the
#chilles ten'on,
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(a)e home message
• Sesis Care B&n'le• Broa' sectr&m antibiotics+ within
8hrs
• Review efficacy within 7hrs
• 2romt 0C referral in case of rai''ecline
• S&sicio&s% Bloo' Gas,
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References
6, Gram Negative Sesis/ a 'ilemma of mo'ern me'icine
htt/www,ncbi,nlm,nih,govmcarticles2MC8H;7>>
7, htt/www,ncbi,nlm,nih,govmcarticles2MC7@666>
8, htt/www,&to'ate,comcontentsgram-negative-bacillary-
bacteremia-in-a'<sabstractH
9,
htt/www,s&rvivingsesis,orgB&n'les2ages'efa<,as5
H, www,me'scae,com
>, www,wi)ie'ia,com
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(han) yo&,
