Bacteremia/Sepsis- SING - EXAM 5

Define bacteremia

presence of bacteria in the bloodstream

Define SIRS

• “systemic inflammatory response syndrome”

• Systemic inflammation from any cause (infection, trauma, burns)

Define sepsis (sepsis 3 definition vs. sepsis 2 definition)

• sepsis-3: life-threatening organ dysfunction caused by a dysregulated host response to infection/ acute change in SODA score ≥ 2

• sepsis-2: SIRS + probably or documented source of infection

Define septic shock (sepsis 3 definition vs. sepsis 2 definition)

sepsis-3: sepsis+ persistent hypotension requiring vasopressors + serum lactate >18 mg/dL

sepsis-2: sepsis+ hypotension refractory to fluid resuscitation (need vasopressors)

Risk factors for bacteremia vs. sepsis:

Bacteremia	Sepsis
advanced age chronic liver disease DM ESRD or HD asplenia HIV infection using immunosuppressants or steroids indwelling prostheses IV drug use malignancy malnutrition/hypoalbunemia neutropenia PVD recent produces (organ transplant, stem cell transplant) trauma urinary retention	advanced age young age HF DM COPD cirrhosis ESRD immunosuppressive diseases (Malignancy, HIV)

Bacteremia and sepsis are typically secondary infections/syndromes. What does mean?

it means they are not the primary (focal) disease but rather complications arising from an initial infection or injury

• ex: a patient with an untreated kidney infection develops bacteremia

Bacteremia can technically be caused by any organism/bacteria, but what are the most common?

• E.coli

• Klebsiella

• P. aeruginosa

• S. aureus

• enterococcus

• S. pneumoniae

What pathogens most commonly cause sepsis? (include bacteria and fungi)

• MOST COMMON BAC

  • E. coli

  • S. aureus

• MOST COMMON FUNGI

  • Candida

Most common sources of sepsis?

SATA:

a. lung

b. intra-abdominal space

c. genital/urinary tract

d. spinal cord

a, b, c

DO YOU HAVE TO HAVE BACTEREMIA TO HAVE SEPSIS?

NO!!! DO NOT NEED BACTEREMIA TO HAVE SEPSIS

Diagnosis of bacteremia:

• how many blood cultures?

  • how are they collected/reported?

• take samples before or after abx administration?

• diagnosis of true infection includes what?

• 2 sets preferred (4 bottles)

  • each set contains aerobic and anaerobic bottle

  • collected from 2 different sites

• obtain samples PRIOR to administration of abx

• diagnosis= detection of organism + clinical s/sx of infection

Diagnosis of sepsis:

• what needs to be identified 1st?

  • how?

• positive ___________

• 1st- IDENTIFY SOURCE OF INFECTION

  • using blood cultures (same method as in bacteremia)

• 2nd- POSITIVE SIRS or SOFA (qSOFA) criteria

What is the definition of each of the following:

(some repeats)

• sepsis 2

  • sepsis

  • severe sepsis

  • septic shock

• sepsis 3

  • sepsis

  • septic shock

• sepsis-2

  • sepsis: SIRS + source of infection

  • severe sepsis: sepsis + signs of end organ damage

  • septic shock: sepsis + hypotension refractory to fluid resuscitation

• sepsis-3

  • sepsis: acute change in SOFA score ≥ 2

  • septic shock: sepsis + persistant hypotension requiring vasopressors + serum lactate >18mg/dL

• tip: think sepsis-3 you need 3 things to diagnose septic shock or think sepsis-2 you need 2 things for each definition

WHAT IS THE SIRS CRITERIA? HOW MANY MUST YOU MEET?

• MEMORIZE THIS********

1. temperature >38C or <36C

2. heart rate >90 bpm

3. respiratory rate >20 breaths/min

4. WBC >12,000 cells/mm or <4,000 cells/mm

   • or >10% bands

• MUST MEET 2 or MORE CRITERIA FOR +

What is the qSOFA criteria? How many must you meet?

1. altered mental status

   • glasgow coma scale <15

2. respiratory rate ≥ 22 breaths/min

3. systolic bp ≤100 mmHg

• MUST MEET 2 or MORE CRITERIA FOR +

Pharm tx for:

• G- bacteremia

  • low risk of pseudo

    • agents

  • high risk of pseudo <10-20% resistance

    • agents

  • high risk of pseudo >10-20% resistance

    • agents

  • route? duration?

G- bacteremia	Tx
Low risk of pseudo	ceftriaxone cefepime ceftazidime piperacillin/tazobactam
high risk of pseudo <10-20% resistance	cefepime ceftazidime piperacillin/tazobactam carbapenem
high risk of pseudo >10-20% resistance	double cover pseudo!!! cefepime or ceftazidime or piperacillin/tazobactam or carbapenem (same options as before) + aminoglycoside or fluoroquinolone

ROUTE: IV

DURATION: 7-14 DAYS

Pharm tx for:

• G+

  • S. aureus

    • agents

    • route? duration?

• G+, S. aureus

  • empiric+ MRSA: vanco or daptomycin

  • MSSA: nafcillin, oxacillin, cefazolin

  • ROUTE: IV

  • DURATION: 4-6 weeks (2 if uncomplicated)

Pharm tx for:

• G+

  • Coagulase - staph

    • agents

    • duration?

• G+, coagulase - staph

  • same as in S. aureus, but different duration

  • DURATION: 5-14 days

Pharm tx for:

• G+

  • strep

    • agents

      • S. pneumoniae?

      • GAS?

    • duration?

• G+, strep

  • ceftriaxone or penicillin G

  • S. pneumoniae: vanco + ceftriaxone

  • GAS: penicillin + clindamycin

  • DURATION: 14 days

tx recs for:

• G+

  • enterococcus

    • agents

      • VRE?

    • duration?

• G+, enterococcus

  • ampicillin or vancomycin

  • VRE: daptomycin or linezolid

  • DURATION: 5-7 days

Review:

List the duration of tx for each of the following:

• G- bacteremia

• G+ bacteremia, S. aureus

• G+ bacteremia, coagulase - staph

• G+ bacteremia, strep

• G+ bacteremia, enterococcus

• G- bacteremia: 7-14 days

• G+ bacteremia, S. aureus: 4-6 weeks (2 if uncomplicated)

• G+ bacteremia, coagulase - staph: 5-14 days

• G+ bacteremia, strep: 14 days

• G+ bacteremia, enterococcus: 5-7 days

List components and recommendations in the sepsis 1-hour performance improvement bundle:

• What are the 3 components?

• Fluid type?

  • Volume?

• Type of antibiotic?

  • Route?

  • Coverage?

  • duration?

• MAP goal?

  • Preferred vasopressor?

• 3 COMPONENTS: Fluid therapy, antimicrobial therapy, vasopressors

• fluid therapy

  • 30ml/kg IV crystalloid

• antimicrobial therapy

  • IV route

  • broad spec—> MRSA and fungal if high risk

  • 7-10 days (longer in fungal)

• vasopressors

  • goal: MAP ≥65 mmHg

  • norepinephrine preferred