Septicaemia

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Blood infection due to various bacteria which may be associated with infection in specific sites (e.g. lungs, urinary tract, gastrointestinal tract) or there may be no specific focus. It is life threatening because it can progress into multi-organ dysfunction and septic shock.

Cause

Organisms commonly involved are Staphylococcus aureus, Klebsiella, Pseudomonas, Staphylococcus epidermidis, fungal (Candida spp), Coliforms and Salmonella spp, Pneumococci, Proteus spp

Risk factors

  • Extremes of age (children, elderly)
  • Diabetes, cancer, immunosuppression
  • Hospital admission
  • Community acquired pneumonia

Clinical features

  • Fever, prostration (extreme tiredness)
  • Hypotension, anaemia
  • Toxic shock is a complication
  • Signs and symptoms of the primary site of infection (e.g. pneumonia)

Differential diagnosis

  • Severe cerebral malaria
  • Meningitis
  • Typhoid fever (enteric fever)
  • Infective endocarditis

Investigations

  • Look for possible primary source of infection
  • Blood: WBC count, culture and sensitivity

(Use the aseptic technique and collect sample(s) for culture and sensitivity, to RRH (if service present) before initiation of treatment)

Management

Septicaemia is a life threating condition, refer to hospital after pre-referral dose of antibiotics.

Treatment LOC

General measures

  • IV fluids
  • Control of temperature
  • Nutrition support (NGT if necessary)
  • Monitoring of vitals and urinary output

If known focus of infection, treat immediately with IV antibiotics as per guidelines. If unknown focus, give:

Adult

  • Gentamicin 7 mg/kg IV every 24 hours or 1.5-2mg/kg IV or IM every 8 hours
  • Plus either cloxacillin 2 g IV every 4-6 hours
  • Or chloramphenicol 750 mg IV every 6 hours

Child

  • Gentamicin 3.5-4 mg/kg IV every 8 hours
    • (neonate: every 8-12 hours)
  • Plus either: Ceftriaxone 50 mg/kg every 8 hours
    • (< 7 days old: every 12 hours)
  • Or cloxacillin 50 mg/kg IV every 4-6 hours
  • Or benzylpenicillin 50,000 IU/kg IV every 4-6hours
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Prevention

  • Protect groups at risk, for example immunosuppressed and post-surgical patients
  • Follow strictly aseptic surgical procedures

Neonatal Septicaemia

Organism causing neonatal septicemia are similar to the ones causing neonatal pneumonia and meningitis. Refer to hospital after pre-referral dose of antibiotics.

Management

Treatment LOC

Supportive care

  • Keep baby warm
  • For high temperature, control environment i.e. (undress), avoid paracetamol
  • Prevent hypoglycaemia (breastfeeding if tolerated/possible, NGT or IV glucose)
  • Ensure hydration/nutrition
  • Give oxygen if needed (SpO2 < 90%)
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First line treatment

  • Give ampicillin 50 mg/kg IV every 6 hours plus gentamicin 5 mg/kg every 24 hours for 10 days

If risk of staphylococcus infection (infected umbilicus or multiple skin pustules),

  • Give cloxacillin 50 mg/Kg IV/IM every 6 hours and gentamicin 5-7 mg/Kg every 24 hours
  • Clean infected umbilicus and pustules and apply gentian violet

If no improvement after 48-72 hours change from ampicillin to:

  • Ceftriaxone 100 mg/kg daily
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Septic Shock Management In Adults

At Emergency Unit

Early recognition and resuscitation with iv crystalloids Or Blood

Empirical Broad spectrum antibiotics Treatment:

  • Early and adequate broad-spectrum antibiotics
  • Intravenous access. Administer 30ml/kg of crystalloids. A large bore cannula, in an adult (gauge 16) is preferred.
  • Urinary catheterization: UOP in an adult is 0.5ml/kg/hr or more, an equivalent of 30-50mls/hr.
  • Transfer for management to ICU if not responding to resuscitation

At ICU, Intubation and Mechanical Ventilation.

  • The recommended tidal volume is kept at 6ml/Kg, with plateau pressure kept at or below 30ml of water.
  • Iv vasopressor Norepinephrine; 5-20µg/min.

Second line is synthetic human angiotensin ii,

  • or vasopressin CVP; 8mmHg
  • Ionotropic therapy and Augumented oxygen therapy
  • Dobutamine up to 20µg/kg/ml

Corticosteroids Therapy:

  • Iv hydrocortisne200mg/Kg/day in 4 divided dosages,
  • Maintenance infusion of methyl prednisolone 1mg/kg/day for 7 days, then tapper down for at least another 7 days.
  • Glycemic control Maintain glycemic level below 180mg/dl through insulin therapy
  • Deep Venous Thrombosis prophylaxis
  • UFH 2 or 3 times a day and LMWH

Disseminated Intravenous Coagulation Management

  • Platelets and plasma transfusion
  • Anticoagulant
  • Fresh Frozen Plasma (FFP)
  • Antifibrinolytic e.g. tranexamic acid 1g 8hly