Sepsis
Nosocomial infections
ABX in the ICU
KARIM FN Brno
Sepsis – definition
 The Third International
Consensus Definitions for
Sepsis and Septic Shock
(2016)
Sepsis - definition
 Sepsis is defined as life-threatening
organ dysfunction caused by a
dysregulated host response to infection
 Organ dysfunction can be identified as
an acute change in total SOFA score ≥2
points consequent to the infection.
Sepsis - definition
 In lay terms, sepsis is a life-threatening
condition that arises when the body’s
response to an infection injures its own
tissues and organs
 Patients with suspected infection who are
likely to have a prolonged ICU stay or to die
in the hospital can be promptly identified at
the bedside with qSOFA
 alteration in mental status
 systolic blood pressure ≤100 mm Hg
 respiratory rate ≥22/min
http://www.qsofa.org/
SOFA score
 Sequential Organ Failure Assessment
Septic shock - definition
 Septic shock is a subset of sepsis in which
underlying circulatory and cellular/metabolic
abnormalities are profound enough to
substantially increase mortality
 Patients with septic shock can be identified with
a clinical construct of sepsis with
 persisting hypotension requiring vasopressors to maintain MAP
≥65 mm Hg
 having a serum lactate level >2 mmol/L (18 mg/dL) despite
adequate volume resuscitation
 With these criteria, hospital mortality is in excess
of 40%.
Sepsis – „OLD“ definition
 Systemic inflammatory reaction (Systemic
Inflammatory Response Syndrome – SIRS) caused
by presumed or confirmed infection
 2 or more of the following criteria :
 Temperature ≥ 38°C or ≤ 36°C
 Tachycardia ≥ 90 bpm
 Tachypnea ≥ 20 bpm or PaCO2 ≤ 4,3 kPa
 WBC ≥ 12 x 109/l or ≤ 4 x 109/l or ≥ 10 % bands
 ALSO define SEVERE SEPSIS – this term should not
be used today
Continuity of the process of
uncontrolled infection
SepsisSIRSInfection/
Trauma Severe Sepsis
Nosocomial infection =
Healthcare Associated Infection
 Definition – infection not present at the hospital
admission and becoming clinically evident after ≥ 48
hours (in most cases)
 Bacterial, viral and fungal etiology
HAI in the ICU – risk factors
 Advanced age
 Severe underlying disease
 Neutropenia
 Immunosuppression
 Intravascular catheters
 Intubation and mechanical ventilation
 Prolonged ICU stay
 Prostheses
 Foreign bodies
Risk factors – cont.
 Bladder catheters and wound drains
 Nasogastric tubes
 Neurological disease with impaired consciousness
 Stress ulcer prophylaxis
HAI in critically ill patients
 Ventilator-associated pneumonia ( VAP )
 Catheter-related infection
 Sinusitis and tracheobronchitis
 Wound infection
 Tertiary peritonitis and other intra-abdominal
infection ( infected pancreatic necrosis, abscesses… )
 Clostridium difficile colitis
 Urinary tract infection
 Acalculous cholecystitis
 Primary gram-negative bacteraemia
 Endocarditis, arthritis, meningitis…
Ventilator-associated
pneumonia
 Early ( 2 - 4 days) and late-onset (≥ 5 days of ICU
stay ) VAP
 Diagnostic criteria :
 New or progressive infiltrate plus ≥ 2 of following :
- fever
- leukocytosis or leukopenia
- purulent sputum
 Invasive procedures – bronchoalveolar lavage ( BAL )
and protected specimen brush ( PSB )
Catheter-related bloodstream
infections ( CRBSI )
 Central venous > peripheral > arterial lines
 For central lines : femoral > internal jugular >
subclavian vein
 Clinical criteria :
 Fever
 Catheter dwell time exceeds 3 days
 Signs of local ( exit-site ) infection
 Positive blood cultures from the intravascular line and
from blood taken peripherally at the same time
Prevention of infection -
general
 General ( enviromental ) preventive measures :
- hand hygiene
- gloves, gowns and face masks
- isolation, cohorting
- cleanliness
- specific architecture and layout of the ICU
enviroment
Prevention of VAP
 Avoiding intubation
 Oral hygiene
 Aspiration of subglottic secretions
 Semi-recumbent body position ( 45° angle )
 Cautious enteral feeding
 Stress ulcer prophylaxis in indicated patients
 Selective decontamination of the digestive tract (
SDD )
- short-term systemic cephalosporin plus long-term
enteral polymyxin, tobramycin and amphotericin
Prevention of CRBSI
 Avoiding femoral route
 Antibiotic / silver impregnated catheters
 Tunneling catheters
 Aseptic technique
- handwashing plus alcohol desinfection
- barrier precautions
- use of proper skin antiseptic agent ( chlorhexidine )
- nurse empowered to stop unsafe practice
 Use of ultrasound
Prevention of CRBSI – cont.
 Post-insertion care
 Avoiding parenteral nutrition
 Removal of CVC whenever indicated
What to consider prior to
administration of antibiotics ?
 Underlying pharmacodynamics and pharmacokinetics
- penetration of an antibiotic agent
- bactericidal x bacteriostatic antimicrobials
- time-dependent killing ( β-lactams and
glycopeptides)
- concentration-dependent killing (aminoglycosides
and fluorochinolons)
- post-antibiotic effect
 Local protocols for initial antibiotic regimen
 Source control of particular infections ( abscess… )
Reassessing initial
management
 Questions :
Is antibiotic treatment necessary at all ? ( day 2-3 )
Should I change the initial strategy ? ( whenever )
Was the treatment successful ( should I stop ATB ) ?
 Length of antibiotic therapy :
- there is no standard duration
- factors regarding the patient ( immune status,
organ dysfunction… )
- properties of the pathogen ( virulence, site of
infection… )
( day 7-10 )
Reduction in selection of MDR
pathogens
 Limit unnecessary antibiotic administration
- education, local guidelines
- local guidelines
- switch to narrow-spectrum antibiotic when culture
results are available !
 Optimise antibiotic effectiveness
- joint ICU rounds with microbiologist
- combination of antibiotics for certain infections
- antibiotic cycling / rotation
- adequate duration of antimicrobial treatment
Rules regarding antibiotic use
 Empirical ATB therapy should be started without
delay in septic patients
 MDR bacteria are not expected in absence of
previous antibiotic use
 Only antibiotics not prescribed in the previous 2
weeks should be considered
 The antibiotic regimen should be targeted based on
rapidly obtained direct tests and modified
according to microbiologic findings
 Use a combination of antibiotics when appropriate
 Prolonging ATB therapy does not prevent recurrence