Bacteremia and Sepsis

Question 1

_____ is simply the presence of bacterial cells in the bloodstream

Answer 1

Bacteremia

Question 2

Respiratory tract infections, especially pneumonia, are the leading cause (or entry point) of _____

Answer 2

sepsis

Question 3

Describe how a bacterial infection in the lungs can spill over into the bloodstreem

Answer 3

• The distance between the blood and the air-filled alveoli is only 2 small epithelial cells thick
  -If pneumonia occurs and the alveoli fill with bacterial colonies and pus, this 2-cell barrier could fail.
• As the infection outside the bloodstream worsens, the epithelial layer is damaged and the bacterial cells can spill over into the bloodstream.

Question 4

Three main areas where Bacteremia can occur

Answer 4

Respiratory tract
GI Tract
Genitourinary tract

Question 5

How does Bacteremia occur in the Gastrointestinal Tract?

Answer 5

• The intestines are very vascular as large amounts of nutrients and fluid are absorbed from the gut.
• There is significant potential for quick entry into the blood for invading pathogens.

Question 6

How does Bacteremia occur in the Genitourinary tract?

Answer 6

• When bacteria invades the urinary tract, we call this a UTI.
• If a UTI is allowed to proliferate, progression up to the kidneys can occur (pyelonephritis)
• The kidneys are highly vascular and the barrier between the urine and the blood is very thin, offering easy entry.

Question 7

Other routes of entry for Bacteremia?

Answer 7

Dental abcesses
Cellulitis in an extremity
Mastoiditis
Strep Throat with a peritonsilar abcess
Infected surgical wound
Sinusitis

Question 8

Bacterial presence in the blood can trigger the immune system with activation of _____

Answer 8

phagocytes

Question 9

T/F Bacteremia will always cause sepsis

Answer 9

F
Bacterial presence in the blood can trigger the immune system with activation of phagocytes.
If the bacteria has a high degree of virulence, or if the patient is immunocompromised, the immune system may initiate a widespread, dysregulated response

Question 10

The largest proportion of pathogens involved in sepsis are ____

Answer 10

Gram positive bacteria - 52.1%

Question 11

T/F Sepsis is always caused by bacteria

Answer 11

F - viruses can cause it too!
Gram positive bacteria- 52.1%
Gram negative bacteria- 37.6%
Polymicrobial infection- 4.7%
Fungi- 4.6%
Viral- < 1% (although considered underdiagnosed)
SARS-CoV-2 was an important recent cause

Question 12

Sepsis is responsible for about ___% of US hospital admissions

Answer 12

6

Question 13

The most common bugs in Sepsis

Answer 13

• Staphylococcus aureus: Respiratory, ENT, Skin
• Streptococcus pneumoniae: Respiratory, ENT
• The Enterococci: Gastrointestinal, Urinary
• Klebsiella pneumoniae: Respiratory
• Pseudomonas aeruginosa: Pneumonia, Urinary, Vascular Access lines, Skin
• Escherichia coli: Urinary, Gastrointestinal

Question 14

_____ is a dysregulated host response to infection that results in life-threatening organ dysfunction

Answer 14

Sepsis

Question 15

Sepsis spectrum is _____

Answer 15

Infection, bacteremia, sepsis, septic shock, multiple organ dysfunction syndrome (MODS), death.

Question 16

Definition of sepsis prior to 2016 (some clinics still use)

Answer 16

Systemic Inflammatory Response Syndrome (SIRS) due to a documented or suspected infection

Question 17

SIRS (Systemic Inflammatory Response Syndrome) = 2 or more of the following abnormalities on physical exam and/or labs

Answer 17

Temp > 100.4 F (38 C) or < 96.8 F (36 C)
HR > 90 beats per minute
RR > 20 breaths per minute or partial pressure of CO2 (PaCO2) < 32 mmHg
White blood cell count (WBC) > 12,000 or < 4,000 cells/mm3

Question 18

Why is the presence of SIRS is not currently the preferred diagnostic definition of sepsis for some experts?

Answer 18

If SIRS is used as the main criteria for diagnosing sepsis, some septic patients may be diagnosed later than ideal, during the shock stages.
- Diagnosed too late

Question 19

In ____, the Society of Critical Care Medicine (SCCM), in collaboration with the European Society of Intensive Care Medicine, published new clinical guidelines for Sepsis

Answer 19

2016

Question 20

T/F the SCCM definitions for Sepsis are unanimously accepted

Answer 20

F

Question 21

The current SCCM’s definition of Sepsis, which was intended to replace the SIRS+infection definition

Answer 21

Sepsis is life-threatening organ dysfunction caused by dysregulated host response to an infection.

Question 22

Organ dysfunction is defined as an ____

Answer 22

acute change in the total Sequential Organ Failure Assessment (SOFA) score by 2 or more points due to infection

Question 23

SOFA

Answer 23

Sequential Organ Failure Assessment

Question 24

SOFA looks at 6 organ systems to determine score:

Answer 24

Lungs/Respiration (using PaO2/FiO2 ratio)
Platelet Count
Liver Function (using Bilirubin level)
Cardiovascular/Blood Pressure
Brain Function (using Glasgow Coma Score)
Kidney Function (using Creatinine)

Question 25

Two scoring systems sometimes used for early identification of those who may go on to develop severe sepsis

Answer 25

qSOFA and NEWS

Question 26

qSOFA

Answer 26

“quick” SOFA is commonly used but is less specific than SOFA. Looks at 3 organ systems: - Lungs/Respiration (respiration rate ≥ 22 per min) - Cardiovascular/Blood Pressure (SBP

Question 27

T/F qSOFA Is a part of the diagnostic definition of sepsis

Answer 27

F Just for screening to identify high-risk patients

Question 28

Examples of clinical evidence that suggest organ dysfunction or tissue hypoperfusion

Answer 28

Vascular: Sepsis-induced hypotension (low SBP or MAP) Heart: Elevated troponin levels Renal: Urine output < 0.5 mL/kg/hour for > 2 hours despite adequate fluid resuscitation, AND/OR Creatinine > 2 mg/dL Liver: Elevated bilirubin Hematologic: Platelet count <100,000 AND/OR elevated INR Hypoperfusion: Elevated Lactic Acid (this is a big one)

Question 29

Sepsis-induced hypotension definition

Answer 29

despite adequate fluid resuscitation, requires vasopressors to maintain a mean arterial pressure (MAP) ≥ 65 mmHg AND have a lactate > 2 mmol/L.

Question 30

Septic shock is associated with a greater risk of ____ than sepsis alone (≥ 40% risk vs ≥ 10% risk)

Answer 30

mortality

Question 31

Diagnostic Studies with Sepsis

Answer 31

CBC with diff CMP (electrolytes, glucose, LFTs, albumin, bilirubin) Serum lactate Arterial blood gases (ABGs) - particularly if hypotensive Amylase and Lipase Urinalysis Blood cultures (2 sets) - as long as does not delay Abx by 45 min Consider cultures from easily accessible sites (sputum, urine, etc.)

Question 32

Diagnostic Imaging Studies with sepsis

Answer 32

Chest X-ray - Common, particularly if respiratory suspect. Abdominal CT if abdominal infection is suspected. CT Head if focal neurologic deficit on exam. Echocardiogram if murmurs or suspected endocarditis. Other applicable imaging (such as US of soft tissues) *Always consider your patient's stability/risk for transport to imaging or invasive procedures

Question 33

A true concern we have in sepsis is the fact that there’s no ___

Answer 33

perfect gold standard test

Question 34

Diagnosing sepsis requires ____

Answer 34

quick critical thinking and clinical reasoning. -We are often initiating treatment based on a suspected diagnosis, deciding this empirically at the bedside upon patient presentation

Question 35

____ are sets of interventions or care processes based on clinical guidelines, that when implemented correctly, contribute positively to quality care

Answer 35

Bundles

Question 36

The following clinical actions should occur between the initial recognition of severe sepsis or septic shock and the 3-hour mark, the SEP-1 bundle:

Answer 36

Serum lactate measurement. Blood/other culture prior to antibiotics. Antibiotic therapy initiated (targeted or broad spectrum). Initial IV fluid therapy of 30 mL/kg of crystalloid (if SBP < 90, MAP < 65, or serum lactate > 4 mmol/L). If initial lactate is > 2, repeat lactate is required prior to 6 hours from initial recognition

Question 37

Hour-1 Bundle Recommends the same actions as SEP-1 occur w/in 1 hour with the strongest evidence supporting:

Answer 37

initiation of the antibiotic within the first hour

Question 38

After SEP-1 or Hour-1 is initiated, what is done necxt?

Answer 38

- Secure airway and give O2 (if indicated). - Lactate and blood cultures should be obtained. - Initiate fluid resuscitation with crystalloid IV fluids - Initiate broad-spectrum antibiotics ASAP - Plan for source control if applicable

Question 39

Which Antibiotic to start with sepsis, with and without shock? What about with MRSA?

Answer 39

Sepsis without shock: 1 broad-spectrum Abx. - Ex: Meropenem (Merrem) or Piperacillin-Tazobactam (Zosyn). With septic shock: combination therapy is advised - Ex: Meropenem or Zosyn, PLUS Vancomycin. Anytime MRSA is a concern, add Vanco

Question 40

Sepsis with a source of CAP often require what antibiotics

Answer 40

Levo or moxifloxacin are often added

Question 41

T/F If the source of sepsis is thought to be fungal, particularly in a patient with neutropenia, antifungal treatment should accompany antibiotic treatment.

Answer 41

T

Question 42

Monitoring for Sepsis during treatment

Answer 42

Monitor response to initial IV fluid resuscitation If refractory hypotension, initiate vasopressor Consider RBC transfusion if hemoglobin < 7.

Question 43

Approximately ___ millions cases of sepsis occur globally each year

Answer 43

48-50

Question 44

Approximately ____ million deaths are attributed to sepsis each year

Answer 44

11

Question 45

The incidence of sepsis seems to vary among racial and ethnic groups, but appears to be highest among ____

Answer 45

black and Hispanic populations

Question 46

Prognosis in Septic patients:

Answer 46

“Severe Sepsis” (sepsis with severe organ dysfunction): Mortality of 25-40%! Septic Shock (sepsis with refractory hypotension) Mortality of 40-80%!

Question 47

Risk of sepsis increases exponentially after the age of ____.

Answer 47

60

Question 48

Common causes of Nosocomial Sepsis

Answer 48

Ventilator pneumonia Surgical site infection Bladder catheter infection Vascular catheter infection