Septicemia

Dr. Mashfiqul HasanResident (Phase A)

Endocrinology & metabolism

Terminology to describe septic patient

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Infection

• Invasion of normally sterile host tissue by microorganisms

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Bacteremia

• Presence of bacteria in blood

• Evidenced by positive blood culture

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Septicemia

• Presence of microbes or toxins in blood

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SIRS

• Two or more of the following conditions:– Fever or hypothermia– Tachypnea– Tachycardia– Leukocytosis or leukopenia or >10% bands

• Infectious / Noninfectious

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Sepsis

• SIRS with proven or suspected microbial etiology

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Severe sepsis

• Sepsis with signs of one or more organ dysfunction– Cardiovascular: hypotension that responds to

administration of IV fluids– Renal– Respiratory – Hematologic – Unexplained metabolic acidosis

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Septic shock

• Sepsis with

– Hypotension, for at least 1 h, despite adequate fluid resuscitation

– Need for vesopressor

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Refractory septic shock

• Last for >1 hour

• Does not respond to fluid or pressor administration

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MODS

• Dysfunction of >1 organ

• Requiring intervention to maintain homeostasis

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Inflammatory response to sepsis

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APPROACH TO SEPTIC PATIENT

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Treatment: Severe Sepsis & Septic Shock

Antimicrobial agents • Without delay

• Appropriate

• IV

• Maximal recommended dose

• Local microbial susceptibility 21

Immunocompetent patient• Any of the following

– Piperacillin-tazobactam– Imipenem-cilastin or meropenem– Cefepime

• If allergic to ß lactam agents– Ciprofloxacin or levofloxacin plus clindamycin

• Vancomycin should be added to each of the above regimen 22

Neutropenic patient• Imipenem-cilastin or meropenem or cefepime

• Piperacillin-tazobactam plus tobramycin

• Vancomycin should be added if indicated

• Empirical antifungal therapy if hypotensive or has been receiving broad spectrum antibiotic

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Other special situations• Splenectomy

– Cefotaxime or Ceftriaxone– Vancomycin plus either moxifloxacin or

levofloxacin or aztreonam

• IV drug user– Vancomycin

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Other special situations: cont• AIDS

– Cefepime or peperacillin-tazobactam plus tobramycin

– Ciprofloxacin or levofloxacin plus vancomycin plus tobramycin

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Source Control

• Evaluation for a focused infection

• Abscess drainage or tissue debridement

Management of hypotension

• Fluid challenge over 30 min• 500–1000 ml crystalloid• 300–500 ml colloid

• Repeat based on response and tolerance

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Management of hypotension

• Vasopressor therapy

– Titrating dose of norepinephrine or dopamine

– Dobutamine if myocardial dysfunction

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Steroid • CIRCI: inadequate corticosteroid activity for the

severity of the illness• Hypotension that does not respond to fluid

replacement therapy• Hydrocortisone, 50 mg IV q6h• If clinical improvement, continue for 5-7 days,

slowly taper• Hastens recovery from septic shock• No increase in long term survival

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Activated protein C• Approved by USFDA

• Indicated for– Very sick patient (APACHE II)– Low risk of hemorrhage

• Complex anti-inflammatory, anti-apoptotic, anticoagulant effect

• Trials going on 30

Glucose control

– Insulin to lower blood glucose to 100-120 mg/dl is potentially harmful

– Needed only to maintain blood glucose below 150 mg/dl

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Other measures• Nutritional supplementation

• Prophylactic heparinization

• Erythrocyte transfusion – When Hb <7 g/dl– Target level 9 g/dl

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Other measures: cont…• Bicarbonate

• Fresh frozen plasma and platelets

• Ventilator support

• Hemodialysis or hemofiltration

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Ongoing trials

• IV Ig

• Endotoxin antagonist (eritoran)

• GM CSF

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