Sepsis - Infeksi App Antibiotika

7/24/2019 Sepsis - Infeksi App Antibiotika

1/26

Sepsis Infection:

The Appropriate Antibiotics

Dr. Veronica Wiwing, SpMK


2/26

Introduction

Causes of death (RSCM, 2010)

1) SIRS & MODS 47.05%

2) Inhalation Injury 39.70%

3) Shock 30.90%

4) ARDS 26.5

5) Sepsis 23.5%


3/26

Introduction

Sepsis @ causa Infection

1) Contributing factors

a) Predisposing:

b) Precipitating: Immunocompromise2) Port dentree

a) Wound infection

b) Bacterial translocation

c) Instrumentation


4/26

The concept of SIRS & MODS

SIRS

Infection

BacterimiaViremia

Parasytemia

Fungemia

T r a u m a

B u r n

Ischemia

Pancreatitis

Sepsis

Diagram: the concept of SIRS and sepsis

Baue, AE, Faist, E, Fry, ED. Multiple organ failure, pathophysiology, prevention, and therapy. New York : Springer, 2000.


5/26


SIRSsystemic Inflammatory response syndrome

SepsisSIRS due to objective (laboratory evidenced)

of infection: bacteremia (toxemia)

MODS

multi system organ dysfunction syndrome(previously: multiple organ failure)

2 or more organs involved



6/26


Shocklack of perfusion

Septic shocksepsiswith hypotension despite adequate

fluid resuscitation

Severe Sepsissepsisassociated with organ dysfunction



7/26

Predisposing

Precipitating

Local effect of Anti

Inflammatory response

Localeffect of Pro

Inflammatory response

Cardiovascular

compromised

Equal CARS-SIRS

Homeostasis Apoptosis

SIRS Predominant SIRS Predominant

Organ

dysfunction CARS Dominant

immune

Suppression

C H A O SCARS Compensatory Anti-inflammatory Response Syndrome MARS Mixed Antagonistic Response Syndrome

Pro Inflammatory response

enter the systemiccirculation

Anti Inflammatory response

enter the systemiccirculation

SIRS Predominant

Systemic Response

CARS

MARS

SIRS

Diagram the cascade of SIRS


8/26

Exaggerated response

Tissue injury SIRS

Immunere

sponsetoinjury

time

recruitmentneutrophil

arachidonic acid production

free radicals

anti-inflammatorypro-inflammatory

compensation

3-5 days

5-21 days

The diagram of the nature of SIRSwith the host immune response to injury point of view


(ARDS)

32 days

CARS

immunosuppressive


9/26


Predisposing factors:

Host / Injury ex : burns devastating injury /

Management (early, advanced)

Precipitating factors (Initiation):

Epithelial damage:

Endothelial (capillary permeability)

Mucosa (disrupted airway mucosa, gut mucosal

disruption, acute tubular necrosis, etc)

Skin-soft tissue necrosis: eschar


10/26


11/26

Infection @ causa burns injury

Host defence Immunosuppresion

Epithelial damage

Port dentre:

Wound infection

Bacterial translocation

Instrumentation

Defenceaggressor homeostasis


12/26

Bacterial Translocation

Splanchnic hypoperfusion lead to ischaemic and

mucosal disruption (epithelialdamage) Altered gut mucosal and intraluminal environment due

to:

Fasting the injured pts

The use of Antacids The use of certain Antimicrobial


13/26

Instrumentation

Disobeyed a and antiseptic handling in procedure of

insertion and maintenance of: Endotracheal tube, tracheostomy tube, suction catheter,

etc

IV lines, CVP lines, syringes

Indwelling catheter Wound management


14/26

Wound infection

Non vital tissue (eschar)

Tissue perfusion Wound degradation

Microorganism: >105/mm3, virulence

Pro-inflammatory Mediators

Immune system suppression


15/26

1. Prevention the development

2. Breaking the cascade

In dealing with SIRS, sepsis and MODS, the treatment

should be:

Listen to what the cells say

The strategy

The management


16/26

The management

Bacterial translocation

The fluid resuscitation:

Adequate volume replacement regarding ischaemic

time (gut mocosa: 4 hrs) Peripheral vasodilator (low dose dopamine)

Gut resuscitation:

No fasting but early enteral nutrition (when the gutworks: use it! to feed the gut rather than to feed the

body) No antacids and H2antagonist

No local antibiotics, no an-aerob antibiotics

No prophylactic antibiotic is needed


17/26

The management

Instrumentation

Aseptic procedure supported with appropriate antiseptic

Everything is single use only No prophylactic antibiotic is needed


18/26

The management

Wound infection

Wound cleaning with dressing

moist dressing for 48 hrs (prevent the wounddegradation)

Early excision:

Tangential excision (necrotomy) followed by

(immediate) skin grafting


19/26

The management

Wound infection (cont)

Haemodynamic stability Limitations:

Manpower (skill), Facilities, donor

Impending SIRS & MODS

The needs for supportive antibiotics

Problems:


20/26

The use of antimicrobial

The rational use of antibiotics:

Standard : class I level of evidence

Guidelines : class II level of evidence

Options : class III level of evidence


21/26

The use of antimicrobialGuidelines

Systemic and topical antibiotics:

Sterile wound

48hr 5 - 7 day

Gram positive mo Gram negative mo

The wound colonization

Shock phase Second phaseImmune-compromize


22/26


Systemic and topical antibiotics should be avoided :

Antibiotic which is cyto-toxic (visceral organs and

wounds) Antibiotic interfering the gut normal flora balance.

Potent antibiotic killing commensal non patogen

bacteria.

Refer to general guidelines.


23/26

Amos F, Grochowski J, Tongol MAS. MIMS antimicrobial guides Indonesia.Singapore: MediMedia Asia. PTE.Ltd.; I(1); 2002

Burns

Common pathogen:

Streptococcus

pyogenes

Enterobacter sp

Staphylococcus

aureusPseudomonas

aurugenosa

Enterococcus sp

Aeromonas

Vancomycin 1g IV bid

&

Amikacin 10mg/kg IV initial,

& 7.5mg/kg IV bid

Piperacillin or 4g IV qid

Ceftazidim 500mg-2g IV 8-12hror

Meropenem (single) 500mg-1g IV tid

Imipenem (single) 500mg-1g tid-qid

Common pathogen:

Streptococcus sp

Topical antibioticswith oral:Silver nitrate 0.5% Moist dressing 2hr

Mafenide acetate cr apply 2-3 times/day

Silver sulfadiazine 1%cr apply 2-3 times/day

Fusidic acid 2% cr/oint apply 2 times/day

Mupirocin 2% cr apply 2 times/day

Penicillins:

Penicillin V 1-2g/day PO devided

dose qid

Penicillin G 2-3 MU IV / 4hr

Macrolides:

Erythromycin 1-2g/day PO devided

dose qid

Wound

sepsis

Cellulitis


24/26


Systemic antibiotics:

Sterile wound

48hr 5 - 7 day

Gram positive mo Gram negative mo

Penicillin (V or G)

Penicillinase resistant

Vancomycin

Avoids:

Carbapenem

ImipenemAminoglycosides

According to mo

succeptibility

No antibiotics


25/26

Conclusion(s)

Guideline for using antibiotic in burns

Effectiveness, non toxic to visceral organs as well aswound

No ideal antibiotic

The use of antibiotic

is a kind of supportive treatment; accomplishment oftreatment sequence

refer to: 1) indication, 2) timing, & 3) clinical condition

supported by a wound biopsy (culture & resistance,histopathology exam)

should be individual and very selective

Use your judgment


26/26

26

How to manage

this Infection ??

Documents

Sepsis - Infeksi App Antibiotika