Sepsis

Clinical Description

Bacteremia: the presence of bacteria in the bloodstream. Sepsis: a life-threatening organ dysfunction triggered by infection.

Signs and Symptoms

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 is 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

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