Sepsis

Question 1

Risk Factors for Sepsis :

1. ___ admission or previous hospitalization
2. ___ infection
3. B ___
4. what kind of pneumonia?
5. Severe acute ___ from covid 19
6. What age ?
7. I
8. C
9. D and O

Answer 1

ICU

nosocomial

bacteremia

CAP

respiratory syndrome

Age >= 65 yrs old

Immunosuppression

cancer

diabetes and obesity

Question 2

Clinical criteria for diagnosis of sepsis?

Clinical criteria for septic shock?

Answer 2

Infection PLUS Increase in SOFA score by >=2

Hypotension requiring vasopressors to maintain MAP >= 65 mmHg AND Serum lactate >18 mg/dL (>2mmol/L) despite adequate fluid resuscitation

Question 3

What are the SOFA criterias?

1. AMS
2. MAP
3. PaO2/FiO2
4. Scr or bili
5. Plts

Answer 3

1. AMS (GCS<15)
2. MAP < 70
3. PaO2/FiO2 < 400
4. Scr or Bili >=1.2
5. Plts < 150

Question 4

If your pt comes in with suspected infection you could also use the SIRS score and NEWS score to assess if they probably have sepsis :

1. How many points does a pt need for SIRS and what are the criteria?
2. HOw many points does pt need for NEWS and what are the criteria?

However, the ultimate decision to deciding whether ur patient has sepsis is?

Answer 4

1. SIRS >=2
   -Temp >38 or <36
   -HR >90
   -RR >20
   -WBC > 12 or <4
2. NEWS >= 3 or 5
   -AMS
   -Temp >38 or <36
   -SBP <=110 , HR >90 or <=50
   -RR>20, O2 sat <96%
3. A SOFA score of >=2

Question 5

Diagosis :

You need to do what if sepsis is suspected?

Send your cultures ___ starting antibiotics

Answer 5

CULTURE IMMEDIATELY

BEFORE

Question 6

Diagnosis and monitoring :

For infection what should u monitor? (5)

Organ (dys) function ? (4)

Answer 6

Infection : Cultures/sensitivities, temp + vitals, CBC w/differntial, PCT, Xray, ultrasound, CT, MRI

chemistry (SCr, LFTs) , lactate, blood gas, coags

Question 7

Goal : identify and control source within how many hours of diagnosis?

Non Drug therapies ? (5)

Consider risk vs benefit by assessing ?

Answer 7

6-12 hrs

Remove infected catheters/lines, change foley catheters, debride soft tissue/wound infections, drain abscesses, surgery

Bleeding, organ injury complications

Question 8

If Shock is present and or sepsis is definite/probable when should you administer antimicrobials ?

If shock is absent, and sepsis is POSSIBLE but not definite, what should u do?

Answer 8

immediately, within 1 hr

Rapid assessment of infectious vs noninfectious causes of acute illness
and administer antimicrobials within 3 hrs if concern for infection persists

Question 9

1. Initiate IV within ??
2. Furthermore, initiate empiric, broad spectrum therapy with ?

Answer 9

1. 1 hr of diagnosis
2. > =1 agents active against the likely pathogen

Question 10

For the following sources, what are the likely bugs?

1. CAP
2. HAP
3. Bacteremia
4. Abdominal infection
5. UTI
6. SSTI
7. Meningitis

Answer 10

1. Strep pneumo, atypicals
2. MRSA, pseudomonas
3. Staph aureus, strep, enterobacter , pseudomonas, candida
4. e coli and bacteroides
5. e coli
6. strep, MSSA, MRSA
7. Strep pneumo, N meningitidis, listeria

Question 11

Empiric Regimen should cover? (3)

Monotherapy may be adequate with the following agents ? (4)
-What kind of infusions should be used?

COnsider double coverage for? (4)

Answer 11

1. GRam neg & gram pos, +/- MRSA, +/- anaerobes
2. 3rd or 4th gen cephalosporins, beta lactam combo agents (zosyn), quinolones, carbapenems
   -Use prolonged infusions

-septic shock or
-neutropenic at high risk for mdr bugs
-MDR pseudomonas or GNR

Question 12

Risk factors for MDR organisms?
1. Proven __ or ___ w/resistant organisms in the prior year

2. local ___ of resistant orgs
3. ___ or ___ associated
4. WHat kind of abx in 90 days?
5. selective ____
6. Traveling to ??
7. ____ within 90 days

Answer 12

1. infection , colonization
2. prevalence
3. hospital, health care associated
4. broad spectrum
5. digestive decontamination
6. highly endemic country within 90 days
7. hospitalization abroad

Question 13

Empiric Monotherapy - Cephalosporins

1. what are the 3 regimens?
2. Advantages?
3. limitations such as less ___, no ___ coverage, and strong inducers of ?
4. What are the holes in spectrum? (3)

Answer 13

1. ceftazidime 1 gm IV q8
   -cefotaxime 1.5 gm IV q12
   -cefepime 1-2 gm IV q 8-12
2. Broad spectrum with low toxicity
   -greater gram neg activity +/- pseudo coverage
3. active against gram pos orgs, entercoccus , ESBL
4. Enterococcus, anaerobes, MRSA

Question 14

Empiric Monotherapy Beta Lactam Combos

1. 2 regimens
2. Advnatages (3)
3. Limitations (1)
4. Holes in spectrum? (3)

Answer 14

1. Ticarcillin/clavulanate (Timentin) 3.1 gm IV q 4-6
   -Zosyn 3.375 gm IV q 6-8
2. Greater gram neg activity, including pseudo.
   -includes gram + organisms +/- anaerobes
   -well tolerated
3. Susceptible to gram + and - bacteria with Beta lactamase
4. MRSA, VRE, ESBL orgs

Question 15

Empiric Monother - Carbapenems

1. list 3 regimens
2. What are the AE’s? (4)
3. Advantages ? (3)
4. Holes in spectrum? (6)

Answer 15

1. Meropenem 0.5-1 gm IV q8
   - imipenem 0.5-1 gm IV q6-8h
   -doripenem 0.5 gm IV q8
2. N/V/D, HA, Rash, Seizures
3. Broad spectrum of activity, greater cell wall penetration and PBP affinity , stable against beta lactamases (but also induces)
4. MRSA, VRE, CoNS, C diff, stenotrophomonas, atypicals

Question 16

Empiric Gram + Therapy

-Cover gram + for which pt’s with sepsis?
-Consider adding MRSA coverage when??
-Discontinue if what?
-Not recc as empiric ___

Answer 16

-ALL PATIENTS

• Prior history of MRSA infection or colonization
• Recent IV antibiotics
• History of recurrent skin infections or chronic wounds
• Presence of invasive devices, hemodialysis
• Recent hospital admissions or high severity of illness

If gram + orgs are ruled out

MONOtherapy

Question 17

Empiric ANTI-Fungal Therapy
-Is this reccomended ?
-Consider in high risk or refractory pt’s such as?

For anti fungal therapy regimen see chart

Answer 17

NO

-Prior fungal colonization and infection
* Prior exposure to prophylactic or therapeutic antifungals
* Immunosuppressed or neutropenic
* Prolonged LOS, devices/lines, TPN
* GI perforation or leakage, recent abdominal surgery

Question 18

See chart for empiric abx regimen for HAP or Immunocomp
-CAP or immunocomp

Question 19

Best Drugs (good suscpetibility) for Pseudomonas? (2)

Which cephalosporins?

Other 2?

Which AG’s?

Which fluoroquinolones?

When should u use double coverage? and what do u add in this case?

Answer 19

1. Cefepime
2. Piperacillin with or w/o Tazo
3. Cefepime or ceftazidime
4. Carbapenem, aztreonam
5. Amikacin > Tobra> Genta
6. Cipro >= Levo, but NOT moxi !
7. Critically ill or neutropenic pt’s, add Aminoglycoside for empiric antipseudo coverage unless ur beta lactam is REALLY good (>85% S)

Question 20

Review allergies to penicillin chart

Answer 20

See chart

Question 21

For vancomycin : What 4 components should u monitor?

For Beta Lactams : what 4 components should u monitor?

For infection : What 6 components should u monitor?

Answer 21

1. Renal function daily
2. levels (DAte and time)
3. PK and AUC
4. Total days
5. Renal function daily
6. CLcr daily
7. dose
8. total days
9. cultures, sensitivities
10. temp q 6 hrs
11. wbc daily
12. lactate daily
13. BP, HR, BG q 6 hrs
14. sx’s

Question 22

How often should u reassess therapy for de-escalation ?

Whats the timeline for narrowing down abx tx?

Whats the tx duration ?

For each of the PCT values for sepsis follow up, state what u should do with abx tx :

1. <0.25
2. 0.25 - 0.49 or drop by >80%
3. > = 0.5 ng/mL and decr by <80%
4. > = 0.5 ng/mL and incr or not decreasing

Answer 22

daily

<= 3-5 days

5-14 days (based on clin response and u should dc abx if NO infectious cause)

1. cessation strongly encouraged (if pt is clinically unstable, consider continuing therapy )
2. Cessation encouraged (if pt is clinically unstable, consider continuing therapy )
3. Cessation DIScouraged (consider expanding coverage and diagnostic eval)
4. Cessation STRONGLY discouraged (consider expanding coverage and diagnostic eval)

Question 23

Bacteremia -Tx duration :

1. Uncomplicated
   - how long from 1st neg blood culture?

Criteria (Must meet all)
-Removable ___
-No ___
-No ___ devices
-Negative ____
-Fever resolved within ?
-No evidence of ?

2. Complicated
   -Tx course?
   -The following are deemed complicated
   E,O,S,I,P,C,M

Answer 23

1. 7-14 days

-focus of infection
-endocarditis
-indwelling
-blood cultures after 2-4 days on IV Abx
-72 hrs after initiating IV Abx
-Metastatic staphylococcal infxn

2. longer tx course

• Endocarditis
• Osteomyelitis
• Septic arthritis
• Infected hardware
• Prosthetic joint infection
• Cardiac device infection
• Meningitis (some cases)

Question 24

Septic Shock Hemodynamics :

What happens to preload, afterload, and contractility ?

What drugs can you use to fix these three aspects?

Answer 24

Preload decreases
afterload decreases
Contractility increases to makeup for these decreases but sometimes when ur heart is tired of contracting it will decr contractility

to increaase preload –> IV fluids

to increase AFTERload –> PRessors

to Fix contractility use inotropes

Question 25

Septic Shock tx (MAP <65) 1. Give ___ within 1st 3 hrs - If MAP < 65 mmHg despite adequate fluid resuscitation what should you do ? 2. If MAP < 65 on low mod dose of NE what should u consider adding ? 3. If after step 2, ur MAP < 65 still, what should u consider adding ? 4. After step 2, if map < 65 and if u have cardiac dysfunction w/persistent hypoperfusion despite adequate volume resusc and BP what should u consider adding ?

Answer 25

1. 30 mL/kg crystalloids - use norepi as 1st line pressor and target MAP >= 65 mmHg 2. COnsider adding vasopressin 0.03 units/min (COnsider IV steroid admin) 3. COnsider epinephrine (Admin IV steroids) -adjunct options dopamine, phenylephrine, angiotensin II 4. Consider adding doutamime or switching to epinephrine

Question 26

Septic SHock TX : IV fluids 1) Suggest ____ over ___ 2) Titrate to __ and __

Answer 26

1. balanced crystalloids , normal saline 2. Hemodynamic response (BP, lower HR, incr urine output ), decr lactate

Question 27

Septic Shock TX : Pressors Which pressors (5) , state whether theyre alpha or beta selective and what this means !

Answer 27

1. Phenylephrine (alpha ) 2. Norepi (Alpha and Beta , more alpha) 3. Epinephrine (alpha and beta, Beta 2 vasodilation***) 4. Dopamine (Alpha and beta ) 5. Dobutamine (Beta , ***Beta2 vasodilation) If more alpha selective, --> Vasoconstriction if more beta selective --> Inotropy with Beta1 receptor /vasodilation with Beta2

Question 28

Norepinephrine (Levo Phed) Pros : Most potent ___ Cons : May incr __ and maybe worsen __ Dose is ? Titrate every ? What should u do prior to NE ?

Answer 28

1. alpha agent, 1st line for septic shock 2. HR, ischemia 3. 0.5-50 mcg/min or 0.05-0.5 mcg/kg/min -1-5 min -fluid resuscitate first

Question 29

Vasopressin (Vasoconstrict) 1) What kind of agent is it ? 2) Dose? 3) Pros ? (3) 4) Cons?

Answer 29

1) works on V1 r's to vasoconstrict 2) 0.01 -0.03 units/min 3) Unique MOA, Synergistic effects, effective in acidosis 4) Not monotherapy, May decr cardiac output at high doses

Question 30

Angiotensin II (Giapreza) 1. Indication ? 2. Dose? -Titrate by ? -Max dose ? -Use with ?

Answer 30

1. INCR BP in septic /distributive shock 2. initiate at 20 ng/kg/min -15 ng/kg/min every 5-15 mins -40 ng/kg/min (80 ng/kg/min in 1st 3 hrs) -DVT prophylaxis

Question 31

Low Dose Steroids - Rec's and Benefits -Can have accelerated __ -Incr ___ -Incr ____ -No clear effect on ____ Typical corticosteroid used in adults w/septic shock is ? -Its suggested that this is commenced at a dose of ?

Answer 31

shock resolution pressor free days neuromuscular weakness short or long term mortality IV hydrocortisone at a dose of 200 mg/d given as 50 mg IV q6hrs or as continuous infusion. -Norepi or epi >= 0.25 mcg/kg/min at least 4 hrs after initiation

Question 32

Glycemic Controll Recc's 1. Target glucose level of ? 2. Initiate insulin for blood glucose of ? 3. Monitoring : Check glucose when ? Avoid what ?

Answer 32

1. 140-180 mg/dL for sepsis 2. >= 180 mg/dL -regular insulin continuous infusion -sliding scale with regular or lispro insulin 3. Check glucose every 1-2 hrs until stable -avoid hyper/hypoglycemia and wide swings

Question 33

Sepsis Supportive Care : Treat what ? Stress ulcer prophylaxis using which agents? DVT prophylaxis using ? Nutrition within ? Ventilator support ! Renal replacement !

Answer 33

pain , agitation, delirium, fever famotidine 20 mg PO/IV q12 -Lansoprazole 30 mg PO/pantoprazole 40 mg IV q24h enoxaparin 30 iu sq q12h heparin 5000 units sq q8h 72 hrs