--- module: 038-01 language: en chapter: 38 title: "Sepsis, Antimicrobial Stewardship, and Infection Prevention" module_title: "Foundations" source_sha256: 86431a303fdb8e6d553791c89d4c1f70793e1ecc9d1c400986ee8b8906d7306e --- # Sepsis, stewardship, and infection prevention ## Sepsis concept and pathophysiology ### Organ dysfunction from dysregulated response to infection #### A syndrome, not a culture result #### May occur without fever or hypotension ### Innate receptors, complement, coagulation, endothelium ### Pro- and anti-inflammatory signals together #### Tissue damage and immune exhaustion ### Vasodilation and leak reduce circulating volume ### Microcirculatory shunting despite adequate pressure ### Lactate is a risk marker and trend #### Normal value does not exclude serious sepsis #### Persistent rise needs reassessment, not automatic fluid ## Recognition and differential diagnosis ### Infection with acute organ deterioration ### Atypical in older, pregnant, neonatal, immunosuppressed #### Neutropenia blunts local inflammation #### Beta blockade blunts tachycardia ### Scores identify risk but do not replace judgement ### Examine likely sources, including devices ### Search for non-infectious mimics ### Septic shock: vasopressor need with raised lactate #### Do not wait for criteria when perfusion fails ## Immediate assessment and cultures ### Airway, breathing, circulation, glucose, urine output ### Reassess after each intervention ### Blood cultures before antibiotics without meaningful delay ### Molecular tests accelerate diagnosis #### May detect colonisation #### Negative panel misses untargeted organisms ## Antimicrobial timing and selection ### Proportional urgency, not one identical clock #### Shock: urgent active therapy after rapid cultures #### Stable and uncertain: focused investigation ### Empirical choice: source, exposure, resistance, host ### Sepsis alters distribution, binding, clearance #### Loading dose despite kidney dysfunction ### Reassess daily: narrow, optimise, define duration ### Improvement does not prove the diagnosis ## Fluids, vasoactive therapy, organ support ### Crystalloid boluses with response assessment #### Fixed large volumes harm limited reserve ### Leg raise, refill, urine, mentation, echo guide fluid ### Norepinephrine first for distributive shock ### Inotropes for selected myocardial dysfunction ### Corticosteroids only in vasopressor-dependent shock ### Lung-protective ventilation, glucose, delirium care ### Transfusion follows oxygen delivery and bleeding ## Source control ### Antibiotics cannot drain pus or remove necrosis ### Drainage, debridement, surgery, relief, device removal ### Act as soon as safely feasible #### Imaging must not delay necrotising or perforation surgery ### Obtain deep cultures ### No improvement: search for another source ## Antimicrobial stewardship ### Best outcome, least toxicity, resistance, cost ### Audit, feedback, allergy clarification, oral switch ### Asymptomatic bacteriuria treated only in defined cases ### Do not treat colonisation or viral syndromes ### Biomarkers support but cannot decide alone ### Duration follows syndrome, source, host, response #### Many infections need shorter courses #### Automatic extension can be harmful ## Precautions and device infection ### Standard precautions apply to every patient #### Gloves do not replace hand hygiene #### Soap and water for soil, spores, outbreaks ### Contact, droplet, airborne routes differ ### Isolation risks loneliness and missed care ### Every device breaches defence #### Continuing indication and daily review ### Urinary catheters: valid indication, early removal ### Ventilator prevention: less sedation, oral care ### Surgical prevention: prophylaxis timing, clipping #### Drains do not justify continued prophylaxis ## Environment and outbreaks ### Cleaning, disinfection, sterilisation differ ### Processing depends on tissue contact ### Organic material impairs disinfection ### Verify, define cases, map person, place, time ### Genomic links need epidemiological context ### Report, preserve specimens, audit control ## Vaccination and recovery ### Vaccines reduce susceptibility and severe disease #### Live vaccines unsafe in immunosuppression, pregnancy ### Staff: vaccination, fit testing, sharps safety ### Needlestick: first aid, consent testing, prophylaxis ### Survivors: weakness, cognition, organ impairment ### Reconcile medicines, record resistance, rehabilitate