20th May 2024

Sepsis and Antimicrobial Prescribing

Sepsis

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The morbidity and mortality burden is significant.

Diagnosis

Whilst most diagnoses of sepsis are made on purely clinical grounds, the clinical diagnosis should actually be based on the patient having an infection and a sequential (Sepsis-related) Organ Failure Assessment (SOFA) score of 2 or more. There is a 2 – 25-fold increased risk of mortality in those with a score of 2 or more.  However, the complexity of the SOFA (table 1) score often precludes its use in clinical settings.

The quick SOFA. (qSOFA) was developed as an alternative bedside tool. If the patient has an infection and fulfils 2 or more of the 3 criteria (respiratory rate 22/min or greater, GCS less than 15 or systolic blood pressure 100mmHg or less), then they are at risk of poor outcomes. A score of 2 or more should prompt further investigations of organ dysfunction and escalation of therapy if required.

Systemic inflammatory response syndrome (SIRS) definitions are no longer required for the diagnosis of sepsis. This is because a significant proportion of septic patients in intensive care units may not actually fulfil the criteria despite being critically unwell.

Septic shock is a subset of sepsis with particularly profound circulatory, cellular and metabolic abnormalities with a higher risk of mortality than sepsis alone. Septic shock can be diagnosed in those with a vasopressor requirement to maintain a mean arterial pressure (MAP) of >65mmHg and a serum lactate of >2 in the absence of hypovolaemia. Septic shock has an in-hospital mortality of >40%.

Management

The management is based on improving tissue oxygenation and perfusion and providing suitable antimicrobial therapy. Often, hospitals use sepsis bundles to protocolise sepsis management to ensure patients receive adequate and timely care. The basics of management include early antibiotic administration (within 1 hour of recognition of sepsis) and fluid resuscitation.

There is no convincing evidence that anything other than crystalloid fluid is superior, although there may be a role for albumin-containing solutions. The volume of fluid to administer varies and there is no optimum. Hypo-perfused patients should receive 30ml/kg of IV crystalloid, however one must be wary of overzealous fluid administration, particularly if the response is poor. Evidence has shown that fluid overload in septic patients is associated with poorer outcomes. For those with a focus on infection, source control should take place within 12 hours.

Early goal directed therapy is sometimes used to protocolise the management of sepsis. This involves physiological targets, namely a MAP of 65mmHg, urine output of 0.5ml/kg/hour, central venous pressure of 8-12mmHg, superior vena cava oxygen saturation of 70% or mixed venous oxygen saturation of 65%. While more recent trials have shown that mortality is not necessarily reduced when the above parameters are adhered to, they are still often used as targets in level 2 and level 3 care of patients with septic shock.

References

• Keeley A, Hine P, Nsutebu E. The recognition and management of sepsis and septic shock: a guide for non-intensivists. Postgrad Med J. 2017 Oct;93(1104):626-634. doi: 10.1136/postgradmedj-2016-134519. Epub 2017 Jul 29. PMID: 28756405.
• National Institute for Health Care Excellence. Sepsis: recognition, diagnosis and early management. London: NICE; 2016.(NICE Guideline No. 51). Available from: www.nice.org.uk/guidance/ng51
• Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane D, Beale RJ, Bellinghan GJ, Bernard GR, Chiche JD, Coopersmith C, De Backer DP, French CJ, Fujishima S, Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad DR, Kleinpell RM, Koh Y, Lisboa TC, Machado FR, Marini JJ, Marshall JC, Mazuski JE, McIntyre LA, McLean AS, Mehta S, Moreno RP, Myburgh J, Navalesi P, Nishida O, Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA, Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson SQ, Singer M, Thompson BT, Townsend SR, Van der Poll T, Vincent JL, Wiersinga WJ, Zimmerman JL, Dellinger RP. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377. doi: 10.1007/s00134-017-4683-6. Epub 2017 Jan 18. PMID: 28101605.

Antimicrobial prescribing

Background

Antibiotic prescribing and stewardship is becoming a more pertinent issue as antibiotic resistance continues to rise.

Antimicrobial stewardship

Antimicrobial stewardship is defined as an organisational or healthcare‑system‑wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness. Thus, the aim is to reduce the risks of inadequate, inappropriate and ill-effects of treatment.

It is important to review antibiotic prescriptions often to ensure that the prescription remains appropriate.

References

• National Institute for Health Care Excellence. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. London: NICE; 2016.(NICE Guideline No. 15). Available from: www.nice.org.uk/guidance/ng15