Sepsis without focus

Sepsis without Focus

Presentation: Ri 侯德斌

Pathogenesis

E.coli Klbesiella Enterobacter Pseudomonas, Serratia Staphylcoccus Toxin mediated: Staphylcoccal or Streptococcal toxic sho

ck, C. difficile,C. sordellii S. pneumoniae N. meningitis Candida species Other causes (less common): Salmonella enteritidis , S. typhi , Plasmodium falciparum , Listeria monocytogenes

Clinical symptom

Classic signs sepsis: fever, chills and hypotension

SIRS:

1) fever (T>38°C) or hypothermia (T<36°C)

2) tachycardia (HR>90), tachypnea (RR>20)

3) leukocytosis (WBC>12,000 or differential w/ >10% bands)

Sepsis

Definition: SIRS + infection (e.g., positive blood culture).

Severe sepsis: sepsis + organ failure, decreased perfusion (lactic acidosis, oliguria, altered mental status) or low BP

Septic shock: hypotension despite fluids + lactic acidosis, oliguria, altered mental status, despite adequate fluid resuscitation.

Special populations and clues

Neonatal (< 1 week): Group B streptococci, E. coli

HIV with CD4< 50 ~100: CMV, TB,Cryptococcus Injection drug users: S. aureus, esp. MRSA Splenectomized pts: Streptococcus pneumoniae,

Haemophilus influenzae, Neisseria meningitidis, Capnocytophaga canimorsus

Neutropenic: GNB, Aspergillus Traveler: malaria, salmonellosis

Special populations and clues

Healthy young adult: Toxic shock syndromes (S. aureus or group A strep),

N. meningitidis, Rocky Mt Spotted fever, bioterrorism ( anthrax, plague, etc),

Ecthyma gangrenosum-- Pseudomonas aeruginosa

petechiae or purpura-- Neisseria meningitidis or Rickettsial infection

Treatment

Empiric: piperacillin-tazobactam 3.375-4.5g IV q6h + vancomycin 15mg/kg q12h +/- tobramycin 5-7mg/kg/d.

Alt: aminoglycoside, e.g., gentamicin or tobramycin 5mg/kg/d or amikacin 15mg/kg/d all IV

Alt: beta-lactam (IV, choose one) : cefotaxime 2g q6h, ceftriaxone 1g q12h, cefepime 2g q12h, ceftazidime 2g q8h, imipenem 0.5-1g q6h, meropenem 1g q8h or piperacillin-tazobactam 3.375g q6h

Treatment

Vancomycin should be dosed 15mg/kg q12h if normal renal function.

Neutropenia: ceftazidime, imipenem or cefepime +/- aminoglycoside.

Intra-abdominal sepsis: ticarcillin-clavulanate, piperacillin-tazobactam, imipenem, all +/- aminoglycoside.

Tissue perfusion maneuvers

Resuscitation: IV fluids Vasopressors Inotropic agent Steroids Blood: transfuse if Hgb <7 g/dL, target goa

l Hgb >7-9 g/dL Activated protein C

Suspected source

Respiratory: Lower respiratory tract infection, such as

mycoplasma and legionella Abdominal : If ultrasound has yielded nothing, the com

puterized tomography (CT) of the abdomen and pelvis is necessary

Urinary tract : urinary cultures

Suspected source

Sinuses : long term nasogastric tubes, Plain x-rays and CT

will demonstrate fluid levels in the sinuses if they are occluded / infected.

Heart: endocarditis is one of the most malignant causes

of systemic sepsis Central nervous system : a brain abscess or meningitis, Tools: brain CT o

r CSF

What else source?

Examine the mouth for dental abscesses; the prostate; the ischeo-rectal area; intravenous catheter; subcutaneous pus collection; bone marrow

Infection of central venous catheter

Exit site infection:

the presence of erythema, tenderness, induration and purulence

Blood stream infection

Defination

Catheter colonisation:

Significant growth of a microorganism in a culture of the catheter tip, subcutaneous catheter segment, or catheter hub.

Catheter related blood stream infection


Bacteremia or fungemia in a patient who has an intravascular device and > =1 positive result of culture of blood samples obtained from the peripheral vein.

Clinical manifestations of infection (e.g., fever, chills, and/or hypotension).

No apparent source for bloodstream infection (with the exception of the catheter).


One of the following should be present: A positive result of semiquantitative ( > =15 cfu per cat

heter segment) or quantitative ( > =100 cfu per catheter segment) catheter culture, whereby the same organism (species and antibiogram) is isolated from a catheter segment and a peripheral blood sample

Simultaneous quantitative cultures of blood samples with a ratio of > =5 : 1 (CVC vs. peripheral)

Differential time to positivity (i.e., a positive result of culture from a CVC is obtained at least 2 hours earlier than is a positive result of culture from peripheral blood)

Pathogen factor

The Biofilm Factor:

Helps these organisms adhere to and survive on the surfaces of foreign bodies

The Thrombin Sheath Factor:

Rich in host-derived proteins, providing adhesion site, like coagulase-negative staphylococci bind to fibronectin, while C

albicans binds to fibrin

PREVENTION

Silver Ions: for short term < 10 days Antimicrobial/Anticoagulant flush Solution: Vancom

ycin hydrochloride,

in combination with heparin sodium or minocycline hydrochloride combined with EDTA

Antimicrobial Impregnation:

combination of either chlorhexidine gluconate and silver sulfadiazine or minocycline and rifampin.

MANAGEMENT

MANAGEMENT

Coagulase-negative staphylococci–5 to 10

daysFor uncomplicated S aureus–related CRB

SIs, it should range from 10 to 14 daysPatients with deep-seated infections (endo

carditis or septic thrombosis) should receive 4 to 6 weeks of treatment

Candidemia

C albicans or C parapsilosis can be treated with fluconazole for at least 14 days after catheter removal

Candida krusei, should be treated with high-dose amphotericin B, 1.0 mg/kg per

day

A study about haematology patients

Table I. Underlying haematological diagnosis in the 87 patients included

Result

Microbiological characteristics of 103 episodes of catheter-related bloodstream infection

Conservatively V.S. central venous catheter removal

Discussion

Hazardous in the presence of characteristic thrombocytopenia?

Difficult patientStudies in this area are generally small,

retrospective, and confined to specific populations

Pathogens vary dramatically between different groups

Discussion

Inappropriateness of applying research findings in one population to practice involving another.

Cancer patient populations have successful conservative management of CR-BSI ranging between 46% and 94%

In dialysis patients typically only 25–37%

Conclusion

Overview all suspected sources Notice the special clue, like Injection drug

users, neonatal, neutropenic patients, etc.Artifact foreign body, like CVC(CVP)Pathogens vary dramatically between diff

erent groups, this fact affects our management decision.

References

Journal of Hospital Infection: Volume 57, Issue 4, August 2004, Pages 325-331

ARCH INTERN MED/VOL 162, APR 22, 2002. Issam I. Raad, MD; Hend A. Hanna, MD, MPH

Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis 2001;32:1249-72.

Sepsis - Unknown Source: John G. Bartlett, M.D. 12-10-2007 N Engl J Med 2006;355:1699-713 Copyright c 2006 Massachusetts Medic

al Society. http://www.ccmtutorials.com/index.htm Pat Neligan December 2006 Univ

ersity of Pennsylvania

Thanks for your attention!

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Sepsis without focus