Sepsis: Concept, symptoms, diagnosis, and treatment

2021-07-22 05:32 PM

With the risk of rapid death from shock and organ failure (multiple organ failure), sepsis is caused by bacteria from a single focus of infection. Initiating bacteria enter the bloodstream many times consecutively.

Sepsis overview - Diagnosisbook supporting video

Sepsis is a collection of clinical manifestations of a severe systemic toxic infection. With the risk of rapid death from shock and organ failure (multiple organ failure), sepsis is caused by bacteria from a single focus of infection. Initiating bacteria enter the bloodstream many times consecutively.

All bacteria with strong or weak virulence can cause sepsis based on weakened resistance or immunosuppression.

Common bacteria causing sepsis

Gram-negative bacteria accounted for 2/3 of cases: Escherichia coli (E.coli), Klebsiella pneumonia, p.seudomonas, Proteus, Yersinia, Neisseria.

Gram (+): Staphylococcus aureus (S.auureus), streptococcus.

Anaerobic Gram (+) bacilli: Clostridium perfringens.

Sepsis: Concept, symptoms, diagnosis, and treatment

Sepsis

Entry tracts and common bacteria

Skin, mucosa: S.auureus, S.pyogenes...

Respiratory, especially lower respiratory tract (pneumonia...): Streptococcus pneumoniae, Haemophilus influenzae, Chlamydia pneumonia, Mycoplasma pneumonia...

Digestive and hepatobiliary: E.coli, K.pneumoniae, other Enterobacteria, anaerobic bacteria.

Urology: E.coli, Enterobacteria...

Dangerous elements

Leukopenia, cancer, HIV/AIDS infection, drug addiction, malnutrition...

Having some diseases: cirrhosis, alcoholism, diabetes, splenectomy, coma, chronic bronchitis.

The elderly, pregnant women, infants.

Concept

Systemic inflammatory response syndrome (SIRS).

SIRS is defined when at least 2 of the following signs are present:

  • Temperature > 38°C or < 35°C.
  • Heart rate > 90 beats/min.
  • Respiratory rate > 20 breaths/min or PaC02 < 32 mmHg.
  • Peripheral blood leukocytes >12G/L or <4G/L or >10% neutrophils.

Sepsis: SIRS is caused by a bacterial infection.

Severe infections (Severe sepsis):

An infection with at least one sign of hypoperfusion or organ dysfunction: cyanosis on the skin, urine <0.5ml/kg/hour, lactate >2mmol/l, altered state of consciousness changes, ECG abnormalities, blood platelets <100 giga/l (G/l), disseminated intravascular coagulation (DIC), ARDS (Acute respiratory distress syndrome) and cardiac dysfunction.

Septic shock:

Septic shock occurs if a severe infection has the following signs:

Mean arterial pressure < 60 mmHg (or < 80 mmHg if the patient has a history of hypertension), maintenance of mean BP > 60 mmHg (or > 80 mmHg if the patient has hypertension) with dopamine > 5 mcg/kg /min, norepinephrine < 0.25 mcg/min or epinephrine < 0.25 mcg/kg/min do not respond to fluid replacement.

Clinical signs

Symptoms of infection, severe systemic toxicity

High fever, continuous chills, can lower the temperature, especially in the elderly and children.

Shortness of breath, rapid breathing, rapid pulse, low blood pressure.

Cold, sweaty skin.

Tired, anorexia, dry lips, dirty tongue, struggling, panicking, urinating less.

Symptoms of the initial foci of infection

Dysuria in urinary tract infections, cough in respiratory infections, meningococcal syndrome, and fever in purulent meningitis...

The reaction of the endothelial reticular system: hepatomegaly, soft liver density, enlarged spleen.

The foci of disease in organs in the body

Lungs: pneumonia, lung abscess.

Nerve: purulent meningitis, brain abscess, extradural abscess...

Liver: liver abscess, biliary tract abscess...

Kidney: renal abscess, pyelonephritis...

Cardiovascular: endocarditis, embolism...

Spleen: splenic abscess, splenic embolism...

Subclinical

Blood culture isolates bacteria.

Blood cultures should be taken before antibiotic use, systematic testing when patients have a fever, chills.

When isolating bacteria with a definite diagnosis and making an antibiotic chart to assess the sensitivity of bacteria to antibiotics.

Complete blood count: white blood cell count increased, the neutrophil count increased.

Disseminated Intravascular Coagulation (DIC) test:

Blood urea, blood creatinine increases when the patient has kidney failure.

AST, ALT increased, blood bilirubin increased.

Basic coagulation: Prothrombin ratio decreased in severe cases.

DIC test: D-dimer, alcohol test, Wonkaulla test...

Differential diagnosis

Malaria

There are epidemiological factors: living or visiting malaria-endemic areas.

Clinical manifestations of malaria: high fever, chills, and sweats, periodic attacks depending on the type of parasite.

Blood tests found malaria parasites.

Typhoid disease

Prolonged fever, digestive disorders, abdominal distention, hepatosplenomegaly, rash.

Widal reaction (+).

Blood cultures, bone marrow transplants, fecal cultures grow typhoid bacteria...

Fever due to deep pus-burning (abscess of liver, lung, sub diaphragm...)

Sometimes this deep pus is the result of a previous episode of sepsis. It is difficult to distinguish deep foci of pus as metastasis or as a solitary abscess. The diagnosis is confirmed by ultrasound or puncture of the abscess with bacterial growth.

Tuberculosis

History of exposure to or previous TB disease.

Fever, cough, shortness of breath, chest pain.

Chest x-ray showed tuberculosis lesions.

Sputum test: tuberculosis bacteria (+).

Specific treatment with antibiotics

Rules

Early treatment. Blood cultures before antibiotic use.

Sufficient dose, high dose, or combination of antibiotics for the duration required for treatment.

Based on the antibiogram to use antibiotics depending on the level of sensitivity.

Apply

When blood culture results are not available, treatment should be based on bacterial conjecture based on the entry route of sepsis and the patient's location.

When blood culture results are available, it is necessary to rely on the antibiogram.

The follow-up to assess the effectiveness of treatment:

If the temperature drops, the general condition improves is a good outcome, continue treatment.

If fever persists, repeat blood cultures, assess clinical and laboratory conditions, antibiotics are being used to adjust antibiotics accordingly.

Antibiotics are used depending on the cause and route of entry:

Board. Initial antibiotic use for sepsis in adults with normal renal function

Patient anatomy

Antibiotics used (Intravenous infusion)

Healthy adults

Antibiotics used: 1. Ceftrlaxon 2 - 4g/day or ticarcillin-davulanate 3.1 g/time x 4-6 times/day or piperacillin-tazobactam 3,375g/time x 4-6 times/day. 2. Imipenem-cilastatin 0.5g/time x 4 times/day or meropenem lg/time x 3 times/day or cefeplm 2g/time x 2 times/day. May be combined with gentamicin or amikacin 5-7mg/kg/day. If the patient is allergic to p-lactam antibiotics, use ciprofloxacin 400mg/time x 2 times/day or levofloxacin 500-750mg/time x 2 times/day combined with clindamycin 600mg/time x 3 times/day. If it is suspected that it may be MRSA, add vancomycin 15 - 20mg/kg/time x 2 times/day

Patients with neutropenic multinodular neutropenia

Antibiotics used: 1. Imipenem-cilastatin 0.5g/time x 4 times/day or meropenem 1g/time x 3 times/day or cefepime 2g/time x 3 times/day. 2. Ticarcillin-clavulanate 3.1g/time x 6 times/day or piperacillin-tazobactam 3,375g/time x 6 times/day in combination with tobramycin 5-7mg/kg/day. Add vancomycin 15 - 20mg/kg/time x 2 times/day if there is an intravenous catheter infection, chemical use or a high rate of MRSA...

Splenectomy patient

Cefotaxime 2g/time x 3-4 times/day or ceftriaxone 2g/time x 2 times/day. If the rate of pneumococcal resistance to cephalosporin is high, add vancomycin. If the patient is allergic to group antibiotics (Hactam, vancomycin 15 - 20mg/kg/time x 2 times/day, combined with ciprofloxacin 400mg/time x 2 times/day or levofloxacin 500 - 750mg/time x 2 times/day or aztreonam 2g/time x 3 times/day

Patients who inject drugs

Oxacillin 6g/day in 3 divided doses in combination with gentamicin or amikacin 5-7mg/kg/day. If the patient is allergic to p-lactam antibiotics and the prevalence of MRSA is high, vancomycin 15-20mg/kg/time x 2 times/day in combination with gentamycin or amikacin

Acquired Immunodeficiency (AIDS)

Cefepime 6g/day divided into 3 times, ticarcillin-clavulanate 3.1g/x 6 times/day or piperacillin-tazobactam 3,375g/time x 6 times/day in combination with tobramycin 5-7mg/kg/day. If the patient is allergic to p-lactam antibiotics, use ciprofloxacin 400mg/time x 2 times/day or levofloxacin 500-750mg/long x 2 times/day in combination with vancomycin 15 - 20mg/kg/time x 2 times/ day, tobramycin 5-7mg/kg/day.

(MRSA: Methicillin-resistant Staphylococcus aureus: methicillin-resistant Staphylococcus aureus)

Meningococcal sepsis

One of the following antibiotics may be used:

Ceftriaxone 2g/time x 2 times/day or cefotaxime 2g/time x 6 times/day.

Penicillin-sensitive meningococcal: penicillin G 18-24 million units/day divided into 6 times.

Meronem 1 g/time (children 40mg) x 3 times 8 hours apart.

Sepsis due to s.aureus

(see also guidelines for the diagnosis and treatment of infections caused by s. aureus).

Sepsis from the gastrointestinal tract or urinary tract

Most are Gram-negative bacteria; antibiotics can be used:

Fluoroquinolone antibiotics: ciprofloxacin 0.5g x 2 times/day in 2 divided doses or pefloxacin 400mg x 2 times/day in 2 divided doses or norfloxacin 200mg/day in 2 divided doses.

3rd or 4th generation cephalosporin antibiotics: ceftriaxone or cefotaxime or cefepime.

Antibiotics can be used alone or in combination with each other or in combination with an aminoglycoside group depending on the severity of the disease: gentamicin or amikacin or netilmicin 4-6mg/kg/day IM or tobramycin.

Suspected hepatobiliary tract infection

Fluoroquinolone antibiotics: ciprofloxacin or Pefloxacin 400mg x 2 times/day (oral or intravenous infusion).

3rd or 4th generation cephalosporin antibiotics: cefoperazone 50-100mg/kg/day (cefoperazone + sulbactam can be used with a dose of cefoperazone 2-4g/day) or cefepime or ceftriaxone or cefotaxime.

Antibiotics can be used alone or in combination with 2 groups together or in combination with aminoglycosides (dose as above) depending on the severity of the disease.

Can be combined with metronidazole: children: 30mg/kg/day, adults: 1g/day divided into 2 times.

Sepsis from the respiratory tract

3rd or 4th generation cephalosporin antibiotics: ceftriaxone or ceftazidime 50-100mg/kg/day intravenously in 2 divided doses or cefepime.

fluoroquinolone antibiotics:

Levofloxacin or m oxifloxacin 400mg (oral) or grepafloxacin 600mg (oral) or Sparfloxacin 200mg (oral)

Antibiotics can be used alone or in combination with 2 groups together or in combination with aminoglycosides (dose as above) depending on the severity of the disease.

Anaerobic bacterial sepsis

Metronidazole: children: 30mg/kg/day in 2 divided doses, adults: 1g/day in 2 divided doses or clindamycin. Drugs are used in the form of oral or intravenous infusion.

If gas gangrene is suspected, penicillin 18-24 million/day divided into 4-6 intravenous infusions can be used.

Infections caused by nosocomial bacteria

Use according to the antibiogram. If an antibiogram is not available, one of the following antibiotics may be used, depending on experience.

The ß-lactam group:

Cefoperazone - sulbactam at a dose of cefoperazone 2 - 4 g/day or ipenem -cilastatin or ticarcillin + clavulanic acid or piperacillin + tazobactam or meropenem.

fluoroquinolone group. Use one of the following antibiotics: levofloxacin or moxifloxacin or grepafloxacin or Sparfloxacin.

Antibiotics can be used alone or in combination with 2 groups together or in combination with aminoglycosides (dose as above) depending on the severity of the disease.

Antibiotic treatment time

The average duration of treatment is 10-14 days or longer depending on the source of infection and the cause of the disease.

Discontinue antibiotics after the patient's fever is gone, the general condition improves, and the laboratory parameters return to normal.

Resuscitation

Circulatory volume compensation

Maintain central venous pressure 8-12cm of water. Measure central venous pressure to adjust infusion rate.

Respiratory resuscitation

Breathing oxygen through the nose or using a bag depending on the patient's condition.

Intubation and artificial ventilation when indicated.

Sputum suction.

Continuous monitoring of pulse, blood pressure, SpO2.

Against kidney failure

When mean blood pressure > 60 mm Hg or maximum > 90 mm Hg, if no urine is available, intravenous furosemide is indicated to maintain stable urine output.

In the presence of acute renal failure, treatment with hemodialysis is indicated.

Treatment of disseminated intravascular coagulation with heparin: Platelet transfusion if thrombocytopenia is severe. Use heparin in the presence of DIC.

Prevention of stress ulcers and gastrointestinal bleeding: Use mucolytic agents and H2 antagonists. One of the following drugs can be used: ranitidine 150mg/day or omeprazole 40mg/day or pantoprazole 40mg/day. orally, by injection, or by slow intravenous infusion.

Extracorporeal blood filtration: Exclude cytokines and chemical intermediates.

Surgical intervention

Depending on the patient's condition and the cause, appropriate intervention is indicated. In severe cases, immediate surgical intervention is required, performing both resuscitation and surgical management.

Related articles:

Paediatrics: Sepsis

Sepsis is a life-threatening condition