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CDHB

Septicaemia

This is life-threatening. 30-50% of patients will die despite appropriate therapy. Early diagnosis and treatment are vital. Those who are apparently well may deteriorate rapidly. Patients are usually toxic and febrile. The patient may be in shock or just look unwell. Those with chronic renal failure or advanced age may have no fever or be hypothermic. Systemic steroids may mask the symptoms and signs.

The various stages that patients with severe sepsis may go through has been defined in Harrisons's "Principles of Internal Medicine". See Harrison's Online 18e Edition. The systemic inflammatory response syndrome (SIRS) is the consequence of a dysregulated host inflammatory response which causes multiple organ dysfunction syndrome (MODS). SIRS may be a response to both infectious and non-infectious disorders. It is defined as being present when two or more of the following criteria are met:

• Temperature >38°C or <36°C.
• Heart rate >90/min.
• Respiratory rate >20/min or PaCO₂ <32.
• WBC >12 x 10⁹/L or <4 x 10⁹/L or >10% bands; may have a non-infectious aetiology.

These criteria need to be interpreted in the context of the individual patient and any comorbidities that may be present.

Prompt treatment with broad spectrum antibiotics and fluid resuscitation is vital if the patient satisfies the above criteria for SIRS even though a definite diagnosis of bacterial sepsis has not been established. Make sure the appropriate cultures have been taken.

Clinical Situations which may predispose to Septicaemia

• Hospitalization – carries a higher associated mortality.
• IV lines (especially if there is local inflammation).
• Urinary catheters.
• Local sepsis.
• Post surgical or obstetric procedures.
• Steroid therapy.
• Advanced age and debility.
• Drug addiction and alcoholism.
• Diabetes mellitus.
• Chronic renal failure.
• Splenectomy.
• Malignancy - leukaemia, myeloma etc.
• Immunosuppressive therapy - neutropaenia etc.

Investigations

• Blood cultures.
• If septicaemia is suspected, urgent antibiotic treatment is necessary. Collect 2-3 sets of blood cultures with an interval as short as 5-10 minutes between venepunctures. Separate venepunctures are important as one set might be contaminated with skin organisms. If antibiotics have been given prior to blood cultures then further cultures may need to be taken at antibiotic trough times.
• The diagnosis is based on culturing organisms from the blood so good technique is essential.
• If endocarditis is suspected 3 venepunctures (6 bottles) should be taken, ideally spaced over 24 hours. If patients are acutely ill they may be taken stat from several sites. If antibiotics have been given during the past 2 weeks do 6 venepunctures (12 bottles).
• Other cultures:
  • Sputum if possible.
  • MSU, throat and nose swab.
  • Swab skin lesions and ears if local sepsis likely.
  • Consider LP if meningitis possible.
  • Aspirate fluid from joints or serous cavities and send aspirated material to laboratory.
  • If IV cannula sepsis is suspected then swab skin over entry site with alcohol. Remove and cut subcutaneous section into sterile container with sterile scissors. Consult Microbiology if these samples have to be stored for more than an hour.
  • CBC + diff, coagulation profile for DIC screen.
  • Na, K, creatinine, glucose, AST, GGT, ALP, bili.
  • CXR.
  • Arterial blood gases.
  • Serum lactate.
• Review recent microbiology culture results if available.

Management

Fluids:

• Resuscitate with sodium chloride 0.9%. Large volumes may be needed, inadequate volume repletion is common.
• If the patient is in shock then a CVP line may be needed and larger volumes of fluid required. Consult ICU.
• If patient remains hypotensive (systolic <80 mm Hg) despite adequate hydration (approximately 2 L over 1 hour) then inotropic support will be needed. Consult ICU.
• Fluid management in septic shock can be difficult.

Monitoring:

• Urine output - If patient hypotensive/shocked a catheter may be needed, but avoid if possible.
• Daily creatinine.
• Arterial blood gases and pulse oximetry - ARDS is common and the patient who has progressive hypoxaemia may need respiratory support.
• Severe acidosis secondary to inadequate tissue perfusion may require partial correction.
• Repeat platelet count and coagulation profile as indicated. If bleeding occurs, this is most likely due to DIC. If so consider platelet transfusion and coagulation factor replacement.

Source - seek source carefully and treat it promptly. Relieve obstructed ureter or biliary system, drain abscesses, remove infected IV cannulae or IV solutions etc.

Antibiotic therapy:

• Initial therapy is based on the likely source of sepsis and the common organisms associated with sepsis from this site. The sections on endocarditis, pneumonia, urinary tract infections, meningitis, cellulitis, bone and joint infections, and the Preferred Medicines List (the Pink Book) will give guidance as to which drugs to use initially.
• In hospitalized patients organisms may have been previously isolated and the sensitivities available.
• If infection is cryptogenic (no primary site identifiable) then IV cefuroxime plus gentamicin is a reasonable choice but this combination will not cover enterococci, anaerobes, Listeria and several other species.
• Reasonable choices include:
  • Cryptogenic sepsis:
    • Community acquired - cefuroxime + gentamicin.
    • Hospital acquired - ceftriaxone + gentamicin + metronidazole.
  • Intra-abdominal sepsis:
    • Amoxicillin + gentamicin + metronidazole.
    • Cefuroxime + metronidazole.
  • Cellulitis: Flucloxacillin.
  • Pseudomonas sepsis:
    • Piperacillin/tazobactam + tobramycin.
    • Ceftazidime + tobramycin.
  • Urinary tract:
    • Gentamicin.
    • Ceftriaxone.
  • Neutropaenic fever/sepsis:
    • Piperacillin/tazobactam 4.5 g IV q8h plus gentamicin 5-7 mg/kg IV in 100 mL sodium chloride 0.9% over 30 min q24h

    or, if there is a history of penicillin allergy,

    • Meropenem 1 g IV q8h plus gentamicin 5-7 mg/kg IV in 100 mL sodium chloride 0.9% over 30 min q24h.

      Note: See the gentamicin/tobramycin dosing guidelines in the Pink Book.

• Oxygen therapy:
  • Give oxygen if patient hypoxic.

Topic Code: 1460