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Several factors are important in the management of patients with sepsis.
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A. Removal of Predisposing Factors
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This usually means decreasing or stopping immunosuppressive medications and, in certain circumstances, giving granulocyte colony-stimulating factor (filgrastim; G-CSF) to the neutropenic patient.
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B. Identifying the Source of Bacteremia
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By simply finding the source of bacteremia and removing it (central venous catheter) or draining it (abscess), a fatal disease becomes easily treatable.
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C. Supportive Measures
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The use of fluids and vasopressors in septic shock is discussed in Chapter 14; corticosteroids have not been shown to be helpful in this setting. Management of disseminated intravascular coagulation is discussed in Chapter 13.
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Antibiotics should be given as soon as the diagnosis is suspected, since delays in therapy have been associated with increased mortality rates, particularly once hypotension develops. In general, bactericidal antibiotics should be used and given intravenously to ensure therapeutic serum levels. Penetration of antibiotics into the site of primary infection is critical for successful therapy—ie, if the infection originates in the CNS, antibiotics that penetrate the blood-brain barrier should be used—eg, third- or fourth-generation cephalosporin—but not first-generation cephalosporins or aminoglycosides, which penetrate poorly. Sepsis caused by gram-positive organisms cannot be differentiated on clinical grounds from that due to gram-negative bacteria. Therefore, initial therapy should include antibiotics active against both types of organisms.
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The number of antibiotics necessary remains controversial and depends on the cause. Table 30–4 provides a guide for empiric therapy. Although a combination of antibiotics is often recommended for “synergism,” combination therapy has not been shown to be superior to a single-drug regimen with any of several broad-spectrum antibiotics (eg, a third-generation cephalosporin, piperacillin-tazobactam, carbapenem). If multiple drugs are used initially, the regimen should be modified and coverage narrowed based on the results of culture and sensitivity testing.
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Directed therapy for gram-negative bacteremia may be treated with as few as 7 days of antibiotic therapy.
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Aillet
C
et al. Bacteraemia in emergency departments: effective antibiotic reassessment is associated with a better outcome. Eur J Clin Microbiol Infect Dis. 2018 Feb;37(2):325–31.
[PubMed: 29164361]
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Rhodes
A
et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017 Mar;43(3):304–77.
[PubMed: 28101605]
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Yahav
D
et al; Bacteremia Duration Study Group. Seven versus 14 days of antibiotic therapy for uncomplicated gram-negative bacteremia: a noninferiority randomized controlled trial. Clin Infect Dis. 2019 Sep 13;69(7):1091–8.
[PubMed: 30535100]