SepsisSepsis

Akmal Sya’roni

Div. Of Tropical and Infectious DiseaseDept. Of Internal Medicine Faculty of Medicine Sriwijaya University/ Moh Hoesin HospitalPalembang Indonesia

DEFINITIONS of SEPSIS: The host’s reaction to invading

microbes or the systemic response to

microbial invasion.

Systemic inflammatory Systemic inflammatory response syndrome(SIRS)response syndrome(SIRS)

Two or more following conditions:1. Fever(> 38c ) or hypothermia

(<36c)2. Tachypnea (> 24/min) or PaCO

2<32.3. Tachycardia( > 90/min ).4. Leukocytosis( WBC>12000, )or

leukopenia (WBC<4000,) or >10% bands form.

sepsis

infections SIRS

BacteremiaFungemiaViremiaParasitemia

Burns

Panreatitis

TraumaSurgery

SepsisSepsis

Definition:Bacteremia:microorganisms in bloodstream

FungemiaViremia# Clinical S/S may be or not.# Almost half septic P’t had Neg culture.

SepsisSepsis

Sepsis or septicemia Clinical syndrome ( SIRS ) + microorganisms or their toxic product

in bloodstream or infection.# Clinical manifectations: chills, fever,

tachycardia ,tachypnea, altered metation.

SepsisSepsis

Septic syndrome ( severe sepsis ):Sepsis + MODS Multiple organ dysfunction

syndrome:# metabolic acidosis,

oliguria,consciousness disturbanced,coagulation

abnormality, acute respiratory failure,abnormal

liver and heart function.

SepsisSepsis

Septic shock:Sepsis + hypotension and

inadequate organ perfusion.# systolic blood pressure(SBP)<

90 mmHg or reduction of > 40 mmHg

from base-line.Refractory septic shock: shock

>1 hr, and does not repond to fluid or pressor administration.

EtiologyEtiology

Gram negative bacteria: 60-70 %Gram positive bacteria: 20-30 %

(Staphylococcus,Streptococcus,Pneumo..)

Fungus : 2-3 % ( Candida spp )Others: Virus (Dengue

fever,Hanta virus, Ebola virus,Herpes virus. Mycobacteria, protozoa.

Predisposing FactorsPredisposing Factors

Malignancy:leukemia,lymphoma,dissemi-nated carcinoma.

Immunosupressed : chemotherapy,

steroid ,organ transplantationIndwelling cath: E-T tube,CVP line, Foley’s tube,drain tube(PTCD, PCN )

Liver cirrhosis,Uremia,DM,Alcoholism.

SepsisSepsis

Poor prognosis:Microbial factor: P.aeruginosaHost factor: immunocompromised host, leukemia, SLE, AIDS, neutropenia.

Septic syndrome: DIC, ARDS, latic acidosis, shock.

PathogenesisPathogenesis

Gram negative sepsis: most from G-I tract, G-U tract,

biliary tract, Resp tract, less: skin ,bone, joint.Gram positive sepsis: cath-related infection, IV drug

abuser, Resp tract, skin & soft tissue

infection

PathologyPathology

Involvement of target organ: Lung: pul edema, hemorrhage,

hyaline menbrane change, & ARDS. Kidney: tubular or cortical necrosis. Heart: patchy necrosis in

myocardium. GI tract: superficial ulcer or

hemorrhage. Vascular: WBC-PLT or fibrin thrombi in the capillaries, DIC.

PathophysiologyPathophysiology

Microbial factors: G(-) : Endotoxin : lipopolysaccharides

(lipid –A) G(+): Exotoxin, streptokinase.

Host mediators:TNF-α, Interleukin-1,6,

cytokine,complement,Kinin.

α

ComplicationComplication

Cardio-vascular system:HypotensionDecreased myocardial contractility

Pooling of blood in the microcirculation

Two phases: early: hyperdynamic phase later : hypodynamic phase

ComplicationComplication

Lung: ventilation- perfusion mismatching

decreased PaO2. increased capillary

permeability increased lung water and

infiltrate @ Sepsis is the leading cause of

ARDS#DDx: pul edema (PCWP>18 mm Hg ) & pneumocystis carinii infection

are similar to ARDS in CXR findings.

ComplicationComplication

Kidney :acute renal failure most due to

acute tubular necrosis(ATN) induced

by hypotension or capillary injury. Oliguria,azotemia,proteinuria.Liver : increased ALT,AST,bilirubin, Alk.P, LDH,CRP.G-I tract: ileus,ulcers, ischemic

bowel.

ComplicationComplication

Coagulation system: Thrombocytopenia, DIC (disseminated intra-vascular coagulation )

Metabolic: latic acidosis impaired of gluconeogenesis and insulin resistant, poor control of blood sugar in diabetic patients.

TreatmentTreatment

Removal of infection source: indwelling catheter,prosthetic device.

Drainage of abscess:Relief of obstruction:hydronephrosis,

CBD obstruction,urine retention.

TreatmentTreatment

DC or hold immunosupressed drugG-CSF for leukopenia (WBC< 1000)Respiratory support: O2 therapy, ventilator, PEEP for ARDS.Hemodynamic support:PCWP:12-15 CVP:10-12 cm H2O, correct anemia.Urine output:30mL/h, furosemide if

need

TreatmentTreatment

Dopamine: keep SBP> 90 mmHg. Low dose: 5-10 ug/Kg/min, dopaminergic effect β-1 adrenergic

effect. High dose:α adrenergic effect.Adrenal insufficiency:prior steroid

use, meningococemia,TB,AIDS. hydrocortisone 50 mg iv q6h.

TreatmentTreatment

Metabolic acidosis: NaHCO3 administered if pH< 7.2

DIC: FFP and platelet transfusion.

successful Tx of underlying disease is essential to reverse both acidosis & DIC

AntibioticsAntibiotics

Urosepsis:GNB most common, B-lactam + aminoglycosideMeningitis: 3rd generation

cephalosporin + crystal penicillin.Endocarditis:PCN or oxacillin + GM.Liver abscess & BTI :cefazolin + GM Intra-abd infection: polymicrobial.

GNB: Gram negative bacili, BTI : Biliary Tract infections,GM : Gentamicin, PCN: Penicilin

AntibioticsAntibiotics

Community acquired pneumonia: pneumococci: PCN, cefotaxime,Rocephin vancomycin. H.influenzae or M.catalarris:2nd cephem Atypical pneumonia: erythromycin or new macrolideHospital acquired pneumonia:GNFGNB MRSA,ESBL-E.coli, K.P,P aeruginosa.

GNFGNB: Glucose Non-fermenting Gram-negative Bacili,

ESBL : Extended Spectrum Beta-lactamase

AntibioticsAntibiotics

Cellulitis: Face & mandible:oral cavity bacteria

Deep neck infection: K.P in diabetic

Extremities:Gr A streptococcus L.cirrhosis:eat raw oester: V.vulnificus

Fourniere’s gangrene Toxic shock syndrome:staph or strepto..

AntibioticsAntibiotics

Asplenic patients: S.pneumoniae, H.influenzae, N.meningitidis PCN or vancomycin + 3rd cephem.

Catheter-associated infection: MRSA,coag-neg- staph,GNB,enterococci

Neutropenic patients: P.aeruginosa.

AntibioticsAntibiotics

NO obvious infectious source: Broad spectrum antibiotics cover, B-lactam + aminoglycoside NEW MEASURES: Anti-endotoxin agents:neutralize effect.

Anti-mediator agents: antagonist of

TNF and interleukin receptor.NO : Nitrit Oxcid

Thank YouThank You