Sepsis

Shelby Remmel

Sepsis exists on a spectrum of severity, ranging from simple infection and bacteremia to septic shock.

Definitions (Sepsis 3)

  • Sepsis: Organ dysfunction (change in total SOFA score ≥ 2 points) from dysregulated host response to infection
  • Septic shock: Sepsis + vasopressor requirement to maintain MAP ≥ 65 mmHg + serum lactate > 2 mEq/dL despite adequate volume resuscitation

 

Evaluation

  • Performing early improves mortality. Various scoring systems (SIRS has fallen out of favor)
  • SOFA: most predictive. Uses PaO2/FiO2, thrombocytopenia, hyperbilirubinemia, hypotension, AMS, kidney injury, urine output. (SOFA score).
  • qSOFA: helpful for rapid evaluation. Uses respiratory rate, hypotension, and mental status.
  • NEWS: uses respiratory rate, oxygen saturation, systolic BP, heart rate, temperature, and mental status. (NEWS Score)
  • Source Evaluation: Cultures before starting antibiotics is preferred. However, do not delay antibiotics if unable to obtain cultures promptly. Blood cx x2 (preferably from peripheral veins via venipuncture), Urine cx. Culture from central access points is okay if central access is present and patient is newly admitted.
    • Consider sputum cx, wound cx, other body fluid cx (thoracentesis, paracentesis, LP, joint aspiration) based on clinical picture.
    • Full body physical exam to assess for SSTI/obvious wounds.
    • Provide source control as soon as possible.
    • Limitations to source control: lines, drains, catheters, ports, hardware, etc.
  • Labs: Lactate, CBC w/ diff, BMP, HFP
    • Consider DIC labs for septic shock if clinical suspicion (LDH, Haptoglobin, Fibrinogen, coags.)
  • Imaging: X-ray, CT, or US depending on suspected source

Management: After screening, early antibiotic administration, and fluid resuscitation

Fluids

  • Initial resuscitation with at least 30 mL/kg (ideal body weight) of balanced IV crystalloid fluid (prefer LR > NS), completed within the first 3 hours.
  • Blood: When Hb < 7 or active and large volume bleed (Hb <8 for CAD, brisk bleed suspected).

 

Antibiotics

  • Earlier = better (septic shock – within 1 hour; sepsis alone – within 3 hours).

 

Empiric treatments should target organisms based on suspected source

 

  • MRSA coverage: Vancomycin/daptomycin (avoid if PNA suspected)/linezolid/ceftaroline
    • Risk factors for MRSA: Previous MRSA infection, known MRSA colonization, close contact with MRSA, cavitation on CXR, dialysis, immunosuppressed, recent abx, recent hospitalization, recent influenza illness.
  • Pseudomonas coverage: Piperacillin-tazobactam/cefepime/gentamicin
    • Preferred for patients with MDR risk factors (recent abx, recent hospitalization, immunosuppression, hemodialysis).
  • Fungal coverage:
    • Fluconazole/micafungin: If high risk for candida (neutropenic, receiving TPN, abdominal surgery, recent antibiotic usage, >1 site of colonization).
    • Liposomal amphotericin if high risk for mucor/Rhizopus or disseminated crypto (uncontrolled DM with sinus pain/proptosis, uncontrolled HIV, immunosuppression with nodules on lung imaging).
  • MDR coverage: opt for –enems
    • During the day, will need ID attending approval.
    • Overnight, can order one dose but will need ID approval for following doses.
  • Anaerobic coverage: Metronidazole/Piperacillin-tazobactam/Ampicillinsulbactam/ Clindamycin
    • Recommended for lung abscess or empyema and intra-abdominal infections.
    • Generally not recommended for aspiration PNA. Consider if poor dentition and higher likelihood of anaerobic involvement
  • Atypical coverage: Consider if concern for community respiratory source (Azithromycin/Levofloxacin/Doxycycline); should be given to any patient admitted to ICU for community-acquired pneumonia.
  • Source Control: If unable to find source despite routine imaging, could consider PET vs tagged WBC scan.
  • De-escalation: When source control obtained, use susceptibilities, MRSA nasal swab results, and clinical evaluation to decide how and when to de-escalate and discontinue antimicrobials. Deescalation should be considered in the first 48 to 72 hours.

 

Post-resuscitation management

Vasopressors

  • Start if MAPs persistently < 65 mmHg after fluid resuscitation via CVC, PICC, or Port, or sometimes briefly peripherally (do not wait to start pressors to place central line - can run peripherally while line is being placed). Target MAP ≥ 65 mmHg. Use lactic acid, mentation, and urine output as guides to adequate perfusion
    • 1st Line NE, 2nd Line Vasopressin, 3rd Line Epi, 4th Line Ang II/Dopamine
    • Need ulcer prophylaxis w/ PPI or H2 blocker (preferably PO if possible)

Steroids

  • For persistent septic shock w/ ongoing pressor requirements, consider IV corticosteroids (particularly beneficial in ARDS, severe CAP).
  • Hydrocortisone 100 mg q8 or 50 mg q6 IV +/- fludrocortisone 50 μg (if concerned for adrenal insufficiency) daily for 7 d or until out of shock.

Additional management

  • NaHCO3 – may be useful if pH ≤ 7.1  
  • Early enteral nutrition (within 72 hours) if possible - low-dose / trickle / trophic rates initially.
  • AVOID beta-blockers unless you think HR compromising cardiac output by limiting diastolic filling/lack of atrial kick in afib; this is a physiologic compensatory response
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