Sepsis: the science that describes infection

Excerpt

1. Sepsis

2. Objectives
Define SIRS / sepsis / severe sepsis / septic shock
Early recognition of Sepsis
Early Goal Directed Therapy

3. Definitions
A continuum of severity describing the host systemic inflammatory response

4. Bacteraemiais simply the presence of bacteria in th
e bloodstream. Gram-negative bacteria account for a
bout 60% of cases and Gram-positive organisms for
40%; in some settings (e.g. ICUs) yeasts such as Can
dida make a small but significant contribution.
Septic shock is a more severe form of sepsis syndro
me, and is associated with severe hypotension and or
gan failure. It is best viewed as a state of profound tis
sue hypoperfusion. Shock complicates about 20% of
cases of bacteraemia, and increases the mortality to
60% or more.

5. SIRS
SIRS –systemic inflammatory response syndrome
Must have at least 2 of the following:
Temperature >38.5ºC or <36ºC
Heart rate >90 beats/min
Respiratory rate >20 breaths/min or PaCO2 <32 mmHg
WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 % immature (band)
forms
SIRS is the body’s response to infection, inflammation, stress.

6. Sepsis and Severe Sepsis
Sepsis –SIRS + suspected or confirmed infection (documented via cultures or
visualized via physical exam/imaging)
Severe Sepsis –Sepsis + at least one sign of organ hypo-perfusion or
dysfunction
Areas of mottled skin Disseminated intravascular coagulation
Capillary refill > 3 secs AKI
UOP < 0.5cc/kg /hr ARDS or acute lung injury (ALI)
Lactate > 2mmol /L Cardiac dysfunction on echo
Altered mental status Plt < 100
Abnormal EEG Troponin Leak

7. Septic Shock
Septic Shock -Severe sepsis plus one of the following conditions:
MAP <60 mm Hg (<80 mm Hg if previous hypertension) after adequate fluid
resuscitation
Need for pressors to maintain BP after fluid resuscitation
Adequate fluid resuscitation = 40 to 60 mL/kg saline solution (NS 5L-10L)
Lactate > 4mmol /L

8. Pathogenesis: In Gram-negative sepsis, the prime initi
ator is a lipopolysaccharide (LPS) component of the bact
erial cell wall (i.e. an endotoxin). Gram-positive bacteria
do not have LPS in their cell wall, but peptidoglycan and l
ipoteichoic acids can have similar effects. In addition, so
me Gram-positive bacteria produce exotoxins (e.g. staph
ylococcal toxic shock toxin). Bacterial cell walls stimulat
e monocytes to produce cytokines such as tumour necrosi
s factor (TNF) and interleukin-1, which are important me
diators of the pathophysiological changes in septic shock
and also lead to activation of neutrophils

9. . Activated neutrophils adhere to each other and to v
ascular endothelium, and probably contribute to vasc
ular and tissue injury. Among the many other mediat
ors that are activated are the coagulation cascade (bo
th the intrinsic and extrinsic coagulation pathways) a
nd vascular mediators such as bradykinin, the arachi
donic acid pathway and nitric oxide

10. Clinical features and diagnosis
The typical features of septic shock are:
• fever (or hypothermia)
• profound and/or prolonged hypotension
• acidosis
• tachypnoea
• hypoxia
• altered mental status.
Septic shock may be associated with acute respiratory dis
tress syndrome, disseminated intravascular coagulation a
nd acute renal failure.

11. Diagnosis may not be straightforward.
• None of the typical features is essential for diagnosis, and it is uncommon
for all to be present simultaneously.
• In certain groups (e.g. the very young, the elderly, the immunosuppressed
), the clinical changes may be subtle.
• Shock may present as a collapse or cardiac arrest.
• There are no consistent or reliable differences distinguishing Gram-positi
ve from Gram-negative infections, though there may be clues to suggest the
microbial aetiology (e.g. the characteristic purpura of meningococcaemia).
The following bacteria are associated with a particularly fulminating course
:
• Neisseria meningitidis(so-called Waterhouse–Friderichsen syndrome)
• Staph. aureus(toxic shock syndrome, usually without bacteraemia)
• Strep. pyogenes(necrotizing fasciitis and/or streptococcal shock syndrom
e)
• Strep. pneumoniae(in splenectomized patients).

12. Important haemodynamic changes in septic s
hock
Normal In shock1
• Cardiac index (litres/minute.m–2) 2.8–3.6 ↑
• Systemic vascular resistance 1760–2600 ↓
index (dyn.second–1/cm5.m–2)
• Oxygen delivery (ml/minute.m–2) 520–720 ↓
• Oxygen consumption 110–140 ↓
(ml/minute.m–2)
NB: Values are variable and may change rapidly

13. SURVIVING SEPSIS CAMPAIGN
STEP 1: Identify SEPSIS
STEP 2: Categorize SEPSIS
STEP 3: Initiate TREATMENT

14. Antibiotics
Cultures / Antibiotics / Labs
Cultures PRIOR to Antibiotics ( 2 Sets, one peripheral and one from any line
older than 48hrs)
IV Abx within 3 hrs in the ED, within 1 hr in the ICU
Broad Spectrum, combination therapy for neutropenic and patients with
pseudomonas risk factors
Vancomycin PLUS Zosyn
Consider need for Source Control !
Drainage of abscess or cholangitis, removal of infected catheters,
debridement or amputation of osteomyelitis

15. Fluid therapy
Central Line Access (Fluid hydration +/-pressor)
1
st
line therapy –fluids, fluids, fluids!
Crystalloid equivalent to colloid
Initial 1-2 Liters(20mg /kg) crystalloid or 500 ml colloid
Careful in CHF patients !!

16. Pressors
Start with Levophed (norepinephrine) as first line therapy +/-Vasopressin
Consider Dopamine peripherally on floor
** This is available in crash cart ** If not responding to fluids, don’t want for
pharmacy to send levophed.

17. Corticosteroids
Use in Septic Shock, if NO response to vasopressors and fluids
HYDROCORTISONE 200mg -300mg / day Divided doses (Q6hrs)
Initial Dose 100mg IV x1
Consider for patients who received etomidate
No need for cosyntropin stim test
Wean Steroids QUICKLY once off pressors

18. KEY TAKE HOME POINTS
Recongnize Sepsis EARLYand determine SEVERITY
EARLY Antibiotics are critical to resolution of shock
RESUSCITATEsevere sepsis and septic shock ASAP
EARLY GOAL DIRECTED THERAPY

19. Infection Prevention and Control i
n Health Facilities

20. Infection Prevention and Control
Policies and procedures aimed at minimising the risk
of transmission of infectious agents.
Aims are to:
Reducing morbidity and mortality
Reduce transmission of infection to other patients/clients
Reducing health care costs
Improving the quality of health care services
PROTECT HEALTH CARE WORKERS ALSO
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21. Risk of Spread of infection in HFs
Health care facilities have been known as venues that
enhance the spread of infections where IPC is not pra
cticed
Spread to other patients, health care workers and co
ntamination is easy in health care facilities because o
f many avenues of contact with body fluids
Infection prevention and control is therefore critical i
n these places.

22. Sources of Spread of Infection
Endogenous
From the patient’s own flora
Most commonly Gastro intestinal tract, Skin
Exogenous
Animate : Other patients, caregivers, healthcare wor
ker, visitors, reservoirs or vectors
Inanimate: Care equipments, devices, physical
environment
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23. Factors contributing to transmission of
Nosocomial Infections
•Ignorance
•Poor attention to hygiene & overcrowding
•Poor use of PPEs
•Lack of an effective infection control program
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24. Other contributory factors
Behavioural-handhygiene,useofPPEsetc
Structural–water,basins,singlerooms
Patientassociated–lowimmunity
Organisational–bedoccupancy,staff-patientratio,i
ncreasepatientmovement
Therapeutic–breachesofnormaldefence
mechanism

25. Patient to patient
Patient to
healthcare worker
Healthcare
worker
to patient
Contact transmission of Health care associated
Infections

26. Principles of Control of Risks
Eliminate the risk
Reduce the risk
Isolate the risk
Control the source of risk
PPE utilisation
Discipline

27. DISEASE
TRANSMISSI
ON
CYCLE
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28. Principles of control
Source control
Animate
Inanimate: Eliminate
Modes of transmission: break chain
Portal of entry –Barriers
Host protection (enhance ability)
Immunoprophylaxis
Chemoprophylaxis
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29. Principles of Control
Common methods for achieving control are:
Administrative controls
Engineering controls
Work practice controls
Use of personal protective equipment (PPE)

30. IPC in the HCF
Education and Training
Provision of resources
Safe work habits: SP ±additional precautions
Engineering and work place controls
Appropriate use of PPE
Vaccination
Post exposure prophylaxis
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31. Concept of Safety Culture
Managements action to improve HCW safety
Workers participation in safety planning
Availability of appropriate PPE
Influence of group norms regarding acceptable safety
practices
Orientation process for new personnel
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32. Engineering Controls
These help isolate or remove the bloodborne patho
gen hazard from the workplace.
Controls such as sharps disposal containers, self-sh
eathing needles, vacutainers with safety features,
mechanical pipetting devices, plastic (instead of gla
ss) tubes, etc.
If there is an engineering control available that will
reduce employee exposure either by removing, eli
minating, or isolating the hazard, it must be used.
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33. Standard Precautions
Approaches designed to reduce the risk of
transmission of microorganisms from bot
h recognized and unrecognized sources
Apply to all patients regardless of diagnosi
s, age or presumed infectious status.

34. Standard Precautions
Standard Precautions combine the major features of
Universal Precautions (UP)and Body Substance Isol
ation (BSI)
SP defines ALLbody fluids and substances as infecti
ous.
An approach to Infection Prevention and Control (IP
C)
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35. Standard Precautions
Every body fluid should
be treated as though
it is potentially infectious

36. SP –Components
Hand hygiene
Use of PPEs
Respiratory Hygiene and Cough etiquette
Safe injection practices
Disinfection and Sterilisation
Healthcare waste management
Housekeeping
Patient placement
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37. Isolation precautions
Used to reduce transmission of microorganisms in h
ealthcare and residential settings.
Two (2) categories of isolation precautions
Standard precautions
Transmission-based precautions.
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38. Transmission-Based Precautions
Contact precautions (for diseases spread by direct
or indirect contact e.g. Cholera, EVDs)
“special contact” -C. difficile and Norovirus
Droplet precautions (for diseases spread by large p
articles in the air e.g. N. meningitidis, Influenza)
Airborne precautions (for diseases spread by small
particles in the air e.g. Tb, chickenpox).
Each type of precautions has some unique
prevention steps that should be taken, but ALL
have standard precautionsas their foundation.
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39. Breaking the chain of transmission
Transmission in Hospi
tal
Contact with contaminate
d blood and body fluids
Contact with objects cont
aminated with blood and
body fluids
Droplets
•Control Measures
•Standard
Precautions
•Contact precautions
•Droplet precautions

40. Key contact precautions
Use clean latex disposable gloves and gown wheneve
r you come in contact with a patient
Remove gloves and gowns immediately following any
contact with a patient
Perform hand hygiene immediately after removing a
ny item of PPE
Avoid touching your face, eyes or mouth with either
gloved or ungloved hands

41. Key contact precautions
Dedicate specific equipment for use with a single pati
ent.
If shared equipment are used, clean and disinfect bet
ween each patient use.
Place patient in single occupancy room wherever pos
sible or cohort when not possible.
All waste from patient room must be bagged and disi
nfected before leaving the room.

42. Precautions contd
Reusable protective clothing should ideally be washe
d in the hospital and not taken home
All linen from cases need to be placed in Highly infec
tious plastic bags (identified) and bags should be spr
ayed with 1:10 bleach solution
HCW who handle linen should handle linen with PP
Es

43. Work Practice Controls
Work practice controls alter how you conduct a task
to minimize the risk of exposure. E.g
Taking an injured person through self care
Using a dustpan and brush to pick up broken glass
or other sharp material
Taking waste out immediately after cleanup
Most importantly: Hand hygiene (Follow 5 momen
ts of hand hygiene)
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44. Develop Personal Safe Work Habits
Wash hands before and after to
uching each patient
Wear fresh pair of gloves with e
ach patient
Wear protective coat and/or ap
ron
Use protective goggles and or f
ace masks.

45. Other important prevention methods to note
Scrupulous hand hygiene –very critical
Adequate disinfection
Correct dilutions of disinfectants (1:10) for bleach
Use of appropriate disinfectants
(Hypochlorite/Household bleach)
Proper use of PPEs
Decontamination of equipments in-between patients
Appropriate waste management -disposal

46. Prevention procedures
Dailychange of diluted disinfectants
Correct aseptic techniques
Proper sterilisation, disinfection, disposal
Education of staff in hospital hygiene
Source isolation

47. Prevention contd
Wash hands with soap and water be
fore and after procedures. Cover bro
ken skin or open wounds with water
tight dressing
Use protective barriers (PPE) such a
s gloves, coats, aprons, masks, face s
hields, Biosafety hoods/laminar flo
w.

48. Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. J Hosp Infect2007;67:9-21
“My 5 Moments for Hand Hygiene”

49. Performing Hand Hygiene
Handwashing
Soap –liquid preferable
Running water
Disposable paper towel
Procedure:
Wet hands and apply soap
Ensure all 5 surfaces of hands
are rubbed vigorously and wa
sh to wrist
Rinse under running water
Dry with paper towel or air d
ry. Noshared towels
Use of Alcohol Hand rubs
Alcohol hand rub or hand sani
tizer
Procedure:
Apply about 5mls of hand san
itizer to palm of hand
Ensure all 5 surfaces of hands
are rubbed vigorously and ext
end to wrist
Allow to dry in air.
If hands are visibly soiled howe
ver, handwashing should be
done instead.

50. Alcohol-based
handrub at point of
care
Access to safe,
continuous water
supply, soap and
towels
2. Training and Education
3. Observation and feedback
4. Reminders in the hospital
5. Hospital safety climate
+
+
+
+
The 5core
components of the
WHO Multimodal
Hand Hygiene
Improvement
Strategy
1. System change

51. Sharp management
Use of new, single-use disposable injection equip
ment or sharps is Manadatory.
Discard contaminated sharps immediately and wit
hout recapping in puncture and liquid proof sharp
containers.

52. Don’ts of Sharp management
Do not re-cap needles
Do Not break, bend, re-sheath or r
euse lancets, syringes or needles
Do Not shake sharps containers to
create space

53. Waste Disposal
Segregate according to International color codes
•Red –Highly infectious
•Yellow –Infectious
•Black –General waste
•Safety box-All sharps
Train all personnel responsible for collecting, handli
ng, transporting and disposal of waste
Ensure appropriate enclosure of waste disposal site t
o prevent scavenging

54. Waste Disposal ….2
Develop policy for disposal of medical waste
•Establish and follow disinfection procedures
•Spray wastebags with (1:10) bleach solution
•Employ double-bagging method
•Use PPE in handling of watse
Appoint someone with oversight responsibilities

56. Healthcare worker safety
Importance
Contact with blood &/ body fluids or
performing a test is a potential health
hazard.
Safety involves taking precautions to
protect yourself, the patient and othe
rs (colleagues, people, environment)
against infection.

57. HCW safety –Why is it Important
Anypercutaneousorpermucosaexp
osuretobloodorbodyfluidrepresen
tsapotentialsourceofinfectionbyb
lood-bornepathogens.E.g.HBV,HC
V,HIV,EVDs.
Ifhealthcareworkersfeeltheycanp
rotectthemselvesfrominfection,the
ycanprovidebettercare.

58. HCW SAFETY PROGRAMMES
Protection of Health care worker(HCW)
from infectious disease or hazardous
situation requires a combination of
strategies.
Adherence to a lot of these measures
promote safety of HCW
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59. ROUTES OF OCCUPATIONAL EXPOSURES
TO INFECTIONS
Direct inoculation throu
gh intact or damaged sk
in
e.g. Needle stick injuries, Scalp
el, broken glass wares –HIV, EV
Ds, HBV, HCV

60. Routes of Exposure
Contact with mucus membranes
Inoculation –needlestick injuries
Inhalation
Ingestion
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61. What do you do if exposed?
Wash cuts and inoculation injuries with soap and ru
nning water. DO NOT SQUEEZE; DO NOT use chem
icals (Bleach, disinfectant etc)
Flush splashes –rinse or irrigate with copious amou
nt of water or saline
Need for a First Aid Kit
Report the incident immediately
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62. IC Programme organisation
Infection Control Committee
Should have a wide representation
A forum for multidisciplinary input
Encourages co-operation & Information sharing
Development of policies and guidelines
Infection Control team
Responsible for day –to –day activities, monitoring and imple
mentation of policies.
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63. Components of the Programme
Procedural policies and practices, Habits (SPs, Use
of PPEs etc)
Education and Training
Protection of the HCW-vaccination, PEP
Safe work habits: Routine practices
Surveillance and incident monitoring and feedback
Outbreak investigation
Research
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64. Components of the Programme/2
Administrative measures
Fiscal and human resources
IPC staffing, supplies & equipment, support of the microbiol
ogy lab
Institutional safety culture and organisational char
acteristics
Hospital design and modification
Rational Use of Antimicrobials
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65. CONCLUSION
Safety is paramount in Health care delivery
DO No Harm to
Yourself
Patient/Client
Environment
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66. Thank you
Questions?
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