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Sepsis/inflammation Flashcards

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1
Q

What are the criteria to diagnose septic shock?

A

-requires a vasopressor to maintain MAP > 65mmHg
-serum lactate >2 in the absence of hypovolemia

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2
Q

What is the mortality associated w/ septic shock?

A

40% or greater

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3
Q

Which Candida species is intrinsically resistant to azoles (fluconazole)?

A

Candida glabrata

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4
Q

The major cause of vasodilation in sepsis is likely mediated by what?

A

ATP-sensitive K channels in smooth muscle
-increases permability of vasc smooth muscle cells to K
-hyperpolariaztion of cell membranes preventing muscle contraction

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5
Q

For pts in vasodilatory shock on high-dose pressors and steroids what agent can be added to improve arterial pressure?

A

Angiotensin 2
-typically see a 45% absolute increase in MAP response when compared to placebo

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6
Q

What effect on the vascular system does angiotensin 2 have?

A

potent vasoconstrictor

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7
Q

In what patient population is angiotensin 2 contraindicated?

A

those on ACE inhibitors

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8
Q

What are the two most common causes of bacterial meningitis in ages 16-50?

A

-Streptococcus pneumoniae
-Neisseria meningitidis

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9
Q

What is most likely to normalize first for pts after an ICU discharge?

A

pulmonary function

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10
Q

What is a type 1 NSTI?

A

polymicrobial w/ GP and GN organisms
-on average have 4 isolates of aerobes and anaerobes
-most common isolates: streptococci, staphylococci, enterococci, E. coli, Klebsiella Pseudomonas, Acinetobacter, Bacteroides, Clostridial species

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11
Q

What is a type 2 NSTI?

A

monomicrobial, usually GAS (Streptococcus pyogenes) or MRSA
-accounts for 15% or less of NSTIs

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12
Q

What is a type 3 NSTI?

A

monomicrobial, most commonly Clostridium, but can be Aeromonas hydrophila or Vibrio vulnificus
-can be any Clostridium species, but usually C. perfringens
-a/w IVD and surgical wounds

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13
Q

What is the most common type of NSTI?

A

type 1 (polymicrobial) making up 50-75% of all infections

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14
Q

What are some risk factors for type 1 NSTI?

A

-DM
-PVD
-obesity
-chronic renal failure
-EtOH abuse

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15
Q

What type of NSTI is Fournier gangrene and Ludwig angina typically?

A

type 1

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16
Q

What is the most common cause of DIC? And other causes?

A

-sepsis
-trauma, malignancy, aortic aneurysms, OB complications

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17
Q

What type of sepsis is DIC classically associated with?

A

gram-negative sepsis

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18
Q

What test is used to check for cryptococcal meningitis?

A

CSF India ink stain

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19
Q

What supplementation can help reduce rates of systemci bacteremia in critically ill patients?

A

-glutamine
-L arginine
-these can reduce systemic bacteremia, immune maintenance, and gut flora preservation

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20
Q

What is the “dangerous area” of the face and what are its borders?

A

-area where venous drainage goes directly into cavernous sinus so any infection can lead to cavernous sinus thrombosis
-triangular area from corners of the mouth to the nasal bridge, to include the lower part of the nose and maxilla

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21
Q

Gram-negative, encapsulated, non-motile bacterium describes which organism?

A

Klebsiella pneumoniae

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22
Q

What culture result is suggestive of MRSA?

A

GPC that is mecA positive

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23
Q

What is the mortality rate of CLABSI?

A

12-25%
-2nd most preventable healthcare acquired infection
-8th leading cause of death in US

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24
Q

Bacteruria is present in what percent of patients after having a catheter for 2 days?

A

25%

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25
What are risk factors for CAUTI?
-female -chronic catheter use -chronic health conditions -at risk populations (elderly, immunocompromised) -improperly placed foleys w/ break in sterile technique
26
What differentiates CA-ASB from CAUTI?
-CA-ASB = catheter associated asymptomatic bacteruria -pt is asymptomatic w/ >/= 10^5 CFU on culture -CAUTI = catheter associated UTI -pt is symptomatic w/ >/= 10^3 CFU
27
What is the treatment for CAUTI?
-GN infection that is otherwise uncomplicated ceftriaxone 1gm daily or cefotaxime 1gm q8hr for 7-14 days -if not in the ICU can consider levofloxacin x5 days
28
Which pts are at risk for candida CAUTIs?
-chronic catheters -anatomic abnormalities -diabetes -chronic abx use
29
What is the mortality rate for VAP?
15-25%
30
What are the risk factors for VAP?
-chronic disease -lung disease -age -aspiration -supine -paralytic use
31
What are risk factors for VAP that are specific to trauma?
-increased ISS -decreased GCS -blunt mechanism of injury -emergent intubation -shock -advanced age -increased transfusion requirements -injury pattern
32
What is the incidence of PNA in pts w/ GCS 3-8?
40%
33
What is the rate of sepsis in hospitalized patients? In ICU pts?
-1-11% -30%
34
What is the rate of septic shock in ICU pts?
15%
35
What is the mortality of septic shock in ICU pts?
30-50%
36
What is the Sepsis 3 definition of sepsis?
-life-threatening organ dysfunction d/t dysregulated host response to infection -organ dysfunction = SOFA score increase of 2 or more
37
What is the Sepsis 3 definition of septic shock?
sepsis with: -hypotension that persists despite adequate fluid resuscitation and requires vasopressors to keep MAP > 65 -lactate >/= 2
38
Which inflammatory mediators are released by the innate immune system in response to sepsis?
-TNF-alpha -IL 6 -IL 10 -TGF-beta
39
What characterizes the immune system of a septic pt?
-persistent impairment of neutrophil function -increased lymphocyte and dendritic cell apoptosis -shift from Th1 to Th2 cytokine profile -increase in T regulatory cells -release of anti-inflammatory mediators -monocyte deactivation -immature myeloid-derived suppressor cells
40
In what percent of pts is no source of sepsis identified?
30-40%
41
What components make up the SOFA score (sequential organ failure assessment)?
-PaO2/FiO2 -PLT count -bilirubin -MAP or pressor requirement -GCS -creatinine -UOP
42
What is the recommendation for fluid resuscitation in septic shock?
30mL/kg of IV crystalloid given in 3 hours or less
43
What factors are associated w/ NSTI?
-immunocompromised -DM -COPD -coronary heart disease -chronic renal insufficiency -history of traumatic injury or surgery -IV drug use
44
What percent of pts w/ NSTI had no predisposing factors?
~20%
45
How does the indirect necrosis d/t the toxins release in NSTIs occur?
-perforating vessel thrombosis -vasoconstriction that worsens tissue hypoxia
46
What are the common aerobic pathogens of NSTIs?
-Streptococcus -Enterococcus -Staphylococcus -Escherichia coli -Klebsiella -Proteus
47
What are the common anaerobic pathogens of NSTIs?
-Clostridium -Bacteroides -Peptostreptococcus
48
What is a type 1 NSTI?
polymicrobial -includes GPC, GNR, and anaerobes (Clostridium) -pts are typically older w/ comorbidities -if leads to shock then mortality is > 50%
49
What is a type 2 NSTI?
involve a group A beta-hemolytic streptococci -can be isolated or w/ Staphylococcus -more related to IVDU so can be a younger population
50
What is a type 3 NSTI?
caused by GN marine organisms -most common is Vibrio vulnificus
51
What percent of NSTIs are polymicrobial?
> 75%
52
On average how many organisms are in a polymicrobial NSTI?
4
53
What are the local early signs of NSTI?
-erythema -warmth -tenderness -myalgia -hypersensitivity
54
What are the late local signs of NSTI?
-hematic/gas bullae -necrosis -purple/blue skin -crepitus -cutaneous anesthesia -sensory/motor loss
55
What are the systemic early signs of NSTI?
-pain out of proportion -swelling -fever
56
What are the systemic late signs of NSTI?
-hypotension -confusion -MOF
57
What labs are suggestive of an NSTI?
-WBC > 15.4, esp. w/ bandemia -Na < 135 -BUN > 15 -CRP > 149 -decreased bicarb -elevated lactate
58
What is the increase in NSTI mortality if care is delayed for > 24hrs?
32% to 70%
59
What antibiotics can be used in pts w/ NSTIs and PCN allergies?
fluoroquinolones w/ additional GN and anaerobic coverage or carbapenems
60
How does cardiac output change (in broad terms) throughout septic shock?
-increases as a normal adaptive stress response -peaks and plateaus during early decompensation -drops off during clinical septic shock when SVR < 800
61
How does systemic vascular resistance change (in broad terms) throughout septic shock?
-decreases as a normal adaptive stress response -nadir and plateaus during early decompensation, or just after -rises relatively quickly during clinical septic shock when SVR < 800
62
What is the definition of a superficial surgical site infection?
-involves only skin or subQ tissue -occurs w/in 30 days of an operation -has at least 1 of: -purulent drainage -localized signs of infection that require opening of superficial wound -positive wound culture
63
What is the definition of a deep surgical site infection?
-involves the fascia and muscle layers -occurs w/in 30 days of operation -has at least 1 of: -purulent drainage from deep incision -fever of 38C or greater, localized pain, or spontaneous dehiscence -abscess in the deep wound
64
What is the definition of an organ space surgical site infection?
-involves the any part of the anatomy that is not the incision which was manipulated during the surgery -has at least one of: -purulent drainage from a drain that is placed -positive cultures from the space -abscess in the organ or space
65
What is the risk of infection in a class 1 surgical wound?
1.5%
66
What is the risk of infection in a class 2 surgical wound?
15%
67
What is the risk of infection in a class 3 surgical wound?
15%
68
What is the risk of infection in a class 4 surgical wound?
40%
69
Which GPC do you need to consider for nosocomial infections?
-S. aureus (wound infections) -S. epidermidis (catheters, shunts, prosthetics) -S. pyogenes (GA beta-hemolytic; post-op wound infections) -E. faecalis (peritoneal and pelvic infections)
70
Which GP bacilli do you need to consider for nosocomial infections?
-clostridium -actinomyces -nocardia
71
Which GN bacilli do you need to consider for nosocomial infections?
-E. coli -klebsiella -proteus -enterbacter -serratia -pseudomonas
72
Which anaerobic do you need to consider for nosocomial infections?
-B fragilis -clostridium
73
In surgical pts what are the most common bacteria found in surgical wound infections?
-S. aureus -Enterococci -E. coli
74
In surgical pts what are the most common bacteria found in bacteremia?
-coag neg staph -S. aureus -enterobacter
75
In surgical pts what are the most common bacteria found in UTIs?
-E. coli -pseudomonas -enterobacter
76
In surgical pts what are the most common bacteria found in respiratory infections?
-pseudomonas -S. aureus -enterobacter
77
In surgical pts what are the most common bacteria found in cutaneous infections?
-S. aureus -pseudomonas -enterococci
78
What is the SBP mortality rate?
25%
79
What is the most common bacteria found in immunocompromised pts?
pseudomonas
80
What is the definition of sepsis using MEWS (modified early warning score)?
-MEWS >/= 5 + infection -medium risk if 2 - 4
81
What are the categories looked at in MEWS?
-SBP -HR -RR -temp -AVPU (alert/reacts to voice/reacts to pain/unresponsive)

Infectious disease (3 decks)

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