Sepsis

exp date isn't null, but text field is

Clinical Description

Bacteremia is the presence of bacteria in the bloodstream.

Sepsis is a life-threatening organ dysfunction triggered by infection.

Clinical Features

The qSOFA (quick Sepsis Related Organ Failure Assessment) score may identify patients with suspected infection with poor outcome; the score ranges from 0-3 with 1 point assigned for each of the following:

  • Tachypnoea (respiratory rate ≥ 22 per minute)
  • Shock (systolic blood pressure ≤ 100 mmHg)
  • Altered mentation (Glasgow coma scale < 15)

The presence of a qSOFA of 2 or more is associated with increased risk of death. 

Organ dysfunction: defined as a SOFA score of 2 or more.

Septic shock: sepsis + vasopressor requirement to maintain a mean arterial blood pressure of > 65 mm Hg and a serum lactate > 2 mmol / L in the absence of hypovolemia.

People at increased risk;

  • HIV+
  • The elderly
  • Patients with comorbidities (e.g. malignancy, heart failure, chronic liver/renal failure)
  • Pregnancy
  • Patients receiving steroids or other immunosuppressive drugs
  • Indwelling devices (IV cannulas or indwelling urinary catheters)

Important causes of sepsis in Malawi

  • Bacterial
    • non-typhoidal Salmonellae – Salmonella typhimurium, Salmonella enteritidis
    • Salmonella typhi
    • Streptococcus pneumoniae
      • E. coli
      • Klebsiella pneumoniae 
  • Disseminated TB
  • Malaria

COMPLICATIONS OF SEPSIS

  • Septic shock
  • Acute kidney injury
  • Disseminated intravascular coagulation
  • Adrenal insufficiency
  • Acute respiratory distress syndrome
  • Ischaemic hepatitis
  • Multi-organ failure
    • a condition in which an infection (usually bacteria) causes a systemic inflammatory response resulting in severe illness.
    • identify cause and treat; accordingly, where possible blood culture should be done before starting treatment.
    • it is common in HIV infected patients and is mainly caused by Pneumococcus and non- typhoidal Salmonella.

INVESTIGATIONS

  • FBC, MRDT, blood culture (take sample before starting antibiotics), urea, electrolytes, and creatinine, random blood sugar, serum lactate, HIV test.
  • Urine analysis/echocardiogram/chest X-ray/Urine TB LAM/ sputum for Gene Xpert/Focused Abdominal Sonography in HIV (FASH)/LP where indicated. 

Treatment

Treatment Objectives

  • Early diagnosis and treatment of sepsis
  • Identify causative agent and treat accordingly
  • Prevent complications

NON-PHARMACOLOGICAL 

  • ABCDE assessment (refer to management of emergencies and trauma for ABCDE)

PHARMACOLOGICAL

  • Fluid resuscitation as necessary
    • if in shock, 30mls/kg bolus of Ringer’s Lactate or Normal Saline
    • watch for signs of pulmonary oedema
  • Correct hypoxia and hypoglycaemia if appropriate
  • Transfuse if Hb < 6 mg / dL
  • If persistent hypotension or respiratory failure manage on HDU / discuss with ICU
  • Antipyretic if high temperature (Paracetamol 1g 6 hourly orally)
  • Observe urine output and vital signs during treatment
  • Always refer to hospital for treatment. In severely ill patients, before referral give:

At the health center 

Adults

  • Give Chloramphenicol 1g IV or IM STAT plus
  • Gentamycin 240 mg slow IV or IM STAT plus
  • Quinine 1200mg IV in 5% dextrose over 4 hours

Hospital treatment:

Adults:

  • Ceftriaxone 2g IV 24 hourly for 7 - 10 days

Alternatively

  • Ciprofloxacin 400 mg IV every 12 hoursly or 500 mg orally 12 hourly plus Benzylpenicillin 2MU IV 6 hourly
  • Switch to oral Ciprofloxacin 500 mg 12 hourly plus Amoxycillin 500 mg 8 hourly, or oral Co-amoxiclav 625 mg 8 hourly, when improved
  • Antibiotics should be given for a minimum of 5 days

Note:

  • Adjust treatment as per blood culture and sensitivity result.
  • If patient not improving, think of tuberculosis or resistant organisms eg Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli and treat accordingly.
  • If intra-abdominal source suspected: Add Metronidazole 500 mg IV or 400 mg orally 8 hourly. If still febrile after 72 hours reassess the patient

SEPSIS IN CHILDREN

  • Bacteremia with two or more of the following:
    • Temperature >38°C or <36°C
    • Tachycardia
    • Tachypnoea
    • White blood cell count >12000/mm3 or <4000/mm3 or >10% immature bands

Causes:

Streptococcus pneumonia, staphylococcus aureus, Salmonella species, haemophilus Influenza b. 

Clinical Features

SIGNS AND SYMPTOMS

  • Fever, Malaise, Headache, Poor appetite, Myalgia, Tachycardia, tachypnea, Seizures, Shock.  

INVESTIGATIONS

  • FBC, Urine dipstick, microscopy and culture, Blood culture, Serum glucose, Lumbar puncture (if indicated), Inflammatory markers: ESR, CRP, Chest Xray.

Treatment

PHARMACOLOGICAL

  • Benzyl Penicillin 50,000 units/kg IV or IM 6 hourly for 5-7 days plus
  • Gentamycin 7.5 mg/kg slow IV or IM 24 hourly for 5 -7 days
  • Adjust antibiotics as guided by microbiology results

If still febrile after 72 hours:

  • Repeat blood culture
  • Look for source of infection
  • Change to Ceftriaxone 50mg/kg IV
  • once daily antipyretics
  • NEVER USE ASPIRIN IN CHILDREN
  • Paracetamol 15mg/kg PO 6 hourly

Complications 

  • Multiorgan dysfunction
  • Septic shock

Disseminated intravascular coagulopathy (DIC)

REFERRAL CRITERIA

Persistent fevers while on second line antibiotics and signs of multiorgan dysfunction

COVID-19 INFECTION

  • Please refer to Malawi National Management COVID-19 guidelines (for prevention, diagnosis, and treatment guidelines). Also refer on vaccination section for COVID-19 vaccine.