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SEPSIS AND SEPTIC SHOCK

Initial Assessment

  1. Definitions (SCC 2016)

    1. Sepsis: “Life-threatening organ dysfunction caused by dysregulated host response to infection”

    2. Septic shock: “Subset of sepsis with circulatory and cellular/metabolic dysfunction associated with higher risk of mortality”

  2. Diagnosis of sepsis

    1. SSC 2016, NICE 2016: No diagnostic test to define sepsis; clinical diagnosis; treat if suspected or at risk of having sepsis

Sepsis-3 2016: Clinical Criteria for Sepsis: Infection Plus Two or More Points from SOFA Score (SeeTable 6-1) If Not in ICU, May Use qSOFA Score (Easier Than SOFA)

  1. Diagnosis of septic shock

    1. Sepsis-3 2016: Despite adequate fluid resuscitation

      1. Vasopressors required to maintain MAP ≥65 mmHg, AND

      2. Serum lactate >2 mmol/L

    2. NICE 2016: Infection + fever/feeling unwell, likely source of infection + clinical indicators (behavior/circulation/respiration) + risk factors for sepsis1 → Stratify risk of severe illness2

Acute Medical Management

  1. Initial resuscitation

    1. SCC 2016

      1. Give at least 30 mL/kg of IV crystalloid (LR, NS) within 3 hours

      2. Draw appropriate cultures (two sets of blood cultures – aerobic and anaerobic, and urine/CSF/sputum/abscess if indicated) only if obtaining cultures does not result in substantial delay to starting antimicrobials

      3. Draw lactate and consider procalcitonin level

    2. NICE 2016

      1. Perform tests including blood cultures, CBC diff, PT/PT, CRP, U/E and creatinine, ABG including glucose and lactate

      2. Give IV fluids

        1. If lactate ≥2 or SBP <90 give IV crystalloid bolus:

          1. Age >16: 500 mL over ≤15 minutes

          2. Age ≤16: 20 mL/kg over ≤10 minutes

          3. Neonates: Glucose-free crystalloid 10–20 mL/kg over ≤10 minutes

        2. If lactate <2, “consider giving intravenous fluid bolus”

  2. Antimicrobials

    1. SSC 2016, NICE 2016: Start IV antimicrobials within 1 hour

    2. SSC 2016

      1. Start empiric broad-spectrum antimicrobials to cover all likely pathogens (bacterial, add fungal or viral coverage if indicated) based on site of infection, local prevalence and resistance, immune defects, age and comorbidities, invasive devices/catheters:

        1. Septic shock: At least two antibiotics of different classes; no specific recommendations; possibilities include a broad-spectrum carbapenem (e.g., meropenem, imipenem/cilastatin, or doripenem) or extended-range penicillin/β-lactamase inhibitor (e.g., piperacillin/tazobactam, ticarcillin/clavulanate) or several third or higher generation cephalosporins

        2. Sepsis without shock or neutropenic sepsis/bacteremia: Do not use routine combination therapy

      2. For all sepsis

        1. If risk of MDR (multi-drug resistant) gram negatives, e.g., Pseudomonas, Acinetobacter, add supplemental gram-negative agent

        2. If risk of methicillin-resistant Staphylococcus aureus (MRSA), add anti-MRSA agent, e.g., vancomycin, teicoplanin

        3. If risk of Legionella, add macrolide or fluoroquinolone

        4. If risk of Candida, add echinocandin (anidulafungin, micafungin, caspofungin); in less ill, echinocandin-intolerant, or non-colonized patients, add a triazole or liposomal amphotericin B

    3. NICE 2016

      1. If meningococcus suspected, use ceftriaxone

      2. If the source or the history of resistant infections is clear, use local antibiotic guidance

      3. If source unclear and no history of previous infection/colonization with resistant microbes:

        1. Age ≥18: Use local antibiotic guidelines

        2. Age ≤17: If no resistance, use ceftriaxone 80 mg/kg q24 hours up to 4 g/day

        3. Age <3 months: Ceftriaxone + Listeria coverage, e.g., ampicillin

        4. Neonates ≤72 hours: Benzylpenicillin + gentamicin

        5. Neonates from community ≤40 ...

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