Types of infections that lead to sepsis
Bacterial>fungal>parasitic>viral>others
Non-septic infections include
Cystitis, local cellulitis, osteomyelitis, Upper Resp Infection, early onset fungal or viral
Diagnosis of sepsis includes
Infection plus greater than or equal to 2 SIRS
Diagnosis of severe sepsis
Infection plus 2 or more SIRS plus diminished perfusion, correct with fluids
First line for treatment of sepsis
Fluids
Diagnosis of septic shock??
Infection plus 2 or more SIRS
Treatment for septic shock
Give fluid with vasopressors
What is a Quick SOFA (qSOFA)
A new bed side assessment to providing criteria to identify patients with suspected infection who likely will have poor outcomes
How many qSOFA criteria are needed to predict prolonged ICU stay and death
2 or more criteria
What are the qSOFA criteria
Altered mentation
systolic blood pressure less than 100
Respiratory rate greater than 22
patient with suspected infection and positive qSOFA should be assess further for? Treat? Lab?
Assess using SOFA for sepsis,
Treat sepsis using fluids, vasopressors to keep MAP >65
Serum lactate should be <2mmol/L (normal 0.6 to1.2)
Management of skin and soft tissue infections
Treatment of mild non-purulent necrotizing infection, cellulitis, or erysipelas
Oral antibiotics: Penicillin Cephalosporins Dicloxacillin Clincamycin
Management of skin and soft tissue infections
Treatment of moderate non-purulent necrotizing infection, cellulitis, or erysipelas
IV antibiotics: Penicillin Ceftriaxone Cefazolin Clindamycin
Management of skin and soft tissue infections
Treatment of severe non-purulent necrotizing infection, cellulitis, or erysipelas
Emergency surgical inspection and debridment inspecting for any necrotizing process
Start empirically on vancomycin and piperacillin/tazobactam (zosyn)
THEN
Culture and sensitivity
Look for monomicrobial or polymicrobial
SIRS criteria
increased WBC, fever, increased heart rate, lower bp
Purulent abcess Mild (no systemic signs of infection) treatment
I and D
Treatment for Purulent infection in patient with: SIRS, >100.4 F, >24 RR, >90 HR, WBC >12,000 cells/mcL
Treat for moderate infect:
I and D C and S Empiric Doxcycline or bactrium Define; MRSA (BACTRIUM) MSSA (Dicloxacilin or cephalexin
Treatment for Purulent infection in patient with: SIRS plus hypotension, WBC <400 cells/mcL, who has went through one round of abx.
Severe treatment:
i and D C and S Empiric rx Vanc or Daptomycin linezolid televacin ceftaroline Define rx Mrsa MSSA
celluiltis caused by
Beta hemolytic strep
Patient obese asking for antibiotis for bilateral lower extremity edema and erythema, dark pigmentation. Patient says its been going on for a long time. The lesions are nontender with bound down plaques, you look closely and see some serous drainage. what do you tell patient
Explain to the patient this is due to venous stasis, antibiotics will not help.
Why is culturing cellulitis not recommeded
staph will grow in culture because of virulent and growth
Duration of treatemtn for cellulities
5 days
Number one treatment for skin condition
wound care
Recurrent cellulitis risk factors
(edema, obesity, eczema, venous insufficiency,
interdigital toe space abnormalities
Recurrent cellulitis tx
3 to 4 episodes per year despite preventive measures:
Antimicrobial prophylaxis:
- pcn, cephalosporin or erythromycin bid x 4–52 wks
- intramuscular benzathine penicillin every 2–4 weeks
Abscess Signs and Symptoms
Redness • Heat • Swelling • Pain • Loss of function • Fluctuant upon palpation
treat for staph
Abscess >5cm
needs draining
pantsvalentivne isolated and susceptible to bactrim,
TCN/Doxicillin, arithromycn clithromycin
CA MRSA
Recurrent abscess
culture
5-10 day course of abx
topical decolonization
family sterilized
clostridial myonecrosis
cellulitis
gangren
Diabetic foot
cellulitis
What is a SOFA and what 6 areas are assessed
Sequential (sepsis related) organ failure assessment 6 areas studied circulation (MAP) coagulation (platelet) central nervous system (GCS) Liver function (bilirubin) respiratiory (FiO2/PaO2) Renal (creatinine/urine volume)
normal bilirubin levels
0.1 to 1.2 mg/dL
Normal creatinine levels
0.6 to 1.2mg/dL
normal serum lactate level
0.5 to 1 mmol/L
Treatment of Severe Nonpurulent infection with Streptococcus pyogenes
penicillin plus clindamycin
Treatment of Severe Nonpurulent infection with Clostridial sporogenes
penicillin plus clindamycin
Treatment of Severe Nonpurulent infection with Vibrio vulnificus
doxycycline plus ceftazidime
Treatment of Severe Nonpurulent infection with Aeromonas Hydrophila
doxycycline plus ciprofloxacin
Treatment of Severe Nonpurulent infection with polymicrobial infection
vancomycin plus piperacillin/tazobactam
Empiric Treatment of Severe purulent infection with?
Vancomycin or ceftaroline or Daptomycin or Linezolid or televancin
Treatment of Severe purulent MRSA infection with
Vancomycin or Ceftaroline Daptomycin Linezolid televancin
Treatment of Severe purulent MSSA infection with
nafcillin
cefazolin
clindamycin
Patient obese asking for antibiotics for lower left extremity erythema. Patient says its been going on for a few days. The lesions are tender , you look closely and see some indistinct borders with streaking what do you tell patient
explain to the patient they will need antibiotic.
start on penicillin
When should cellulitis be covered for MRSA
Patient has; nasal colonization evidence of MRSA elsewhere hx of iv drug use traumatic injury
Treatment for cellulitis?
Treat for Beta hemolytic strep
penicillin
cephalexin and tmp/smx
Treat for cellulitis and MRSA?
treating for MRSA and strep Vancomycin or linezolid or clindamycin
What can be used for non-antimicrobial treatment of cellulitis? how long?
corticosteroids (in non-DM) for 5 days
Predisposing factors causing reoccurring cellulitis
obese venous stasis edema eczema foot wounds (interdigital toe space abnormalities)
Treatment for a patient with reoccurring cellulitis 3 to 4 times a year despite preventive measures should be?
antimicrobial therapy:
PCN, cephalosporin, erythromycin BID x 4 to 52 weeks
or
intramuscular benzathine penicillin every 2-4 weeks
CA-MRSA is most likely when patient meets what criteria
1) MRSA was found 48 hours within admission to hospital
2) no history of admission to any facility or dialysis within last year
3) no medical history of MRSA infection or colonization
4) no indwelling catheter being used
5) Susceptible to >2 non-Beta-lactam antimicrobials
Empiric treatment for purulent cellulitis without abscess
with coverage for MRSA
Clindimycin plus Trimethprim-sulfamethoxazole plus doxycycline (minocycline)
Treatment for necrotizing faciitis? what to suspect in culture?
1) surgical debride
2) Culture
3) Emipric treatment Vanc plus Zyson plus ceftriaxzone
4) Confirm with Group A Strep (treat with penicillin plus clindamycin)
