--- module: 038-02 language: en chapter: 38 title: "Sepsis, Antimicrobial Stewardship, and Infection Prevention" module_title: "Dynamic sepsis care, diagnostic stewardship, and interruption of transmission" source_sha256: a5142afa8b3587a3475d3e62cbb13cb20c18751cfc4eb09ec6adba5c1b9e0676 --- # Dynamic sepsis care and transmission ## Recognition as a parallel process ### Neither suspicion nor dysfunction is specific #### Pneumonia can cause hypoxaemia alone #### Mimics: pancreatitis, bleeding, embolism, adrenal crisis ### Treat reversible threats while building evidence ### Response to intervention changes probability ## Heterogeneous circulation and organ failure ### Mediators lower tone and raise permeability #### Effective arterial volume falls despite excess water ### Heart strain, arrhythmia, ventilation limit output ### Regional oxygen failure with acceptable pressure ### Same pressure, different response by perfusion ### ARDS raises permeability, reduces aerated lung ### Kidney injury is more than low flow ### One failing organ burdens others #### Trajectory and reserve over a single score ## Lactate interpretation ### Adrenergic glycolysis raises lactate with oxygen ### Liver clearance, seizures, beta agonists, thiamine ### Forcing normalisation with fluid causes congestion ### Read with refill, skin, mentation, urine, ultrasound ## Fluid as a therapeutic trial ### Balanced isotonic crystalloid by severity ### Ask: stroke volume, perfusion, congestion ### Passive leg raise as reversible challenge ### Variation indices need suitable rhythm and ventilation ### Static venous pressure predicts poorly ### Responsive does not mean fluid is needed ### Reassess congestion after each bolus #### No perfusion gain with congestion: stop repeating ## Vasopressors and inotropes ### Norepinephrine early for profound hypotension #### Peripheral vein avoids harmful delay #### Watch site and act on extravasation ### Vasopressin can spare norepinephrine ### Epinephrine can raise lactate and arrhythmia ### Inotropes only for low output with hypoperfusion ### Rising requirement is not simple underdosing #### Reassess bleeding, tamponade, source, acidaemia ## Antibiotics and diagnostic stewardship ### Urgency proportional to likelihood and consequence #### Shock, meningitis, neutropenia: immediate therapy #### Stable weak evidence: focused diagnostic interval ### Adequate first dose, loading often preserved ### Separate sites with sufficient culture volume #### Underfilling lowers sensitivity #### Contamination drives unnecessary therapy ### Urine culture only when infection is plausible ### Panels miss off-panel organisms, find carriage ### Right specimen first, not blanket withholding ## Source control ### Turns an antimicrobial problem into an anatomical one ### Delay sustains growth, toxin, and inflammation ### Unstable necrotising cases may need exploration first ### Deep samples, since swabs misdirect therapy ### Plan: what, who, when, prepared physiology ### High risk: drainage, staging, device exchange ### Check residual collections and re-obstruction ## Reassessment and stewardship ### Reassess within hours, not at course end ### Narrow when organism and susceptibility reliable ### Culture-negative sepsis has several causes ### Persistent fever does not prove narrow cover ### Stewardship protects the treated patient first #### Less toxicity, C. difficile, microbiota disruption ### Asymptomatic bacteriuria shows diagnostic harm #### Pyuria and cloudy urine are nonspecific #### Culture must explain new invasion first ## Interrupting transmission ### Hierarchy: eliminate, engineer, systems, protection ### Hand hygiene fails with poor access or staffing ### Unchanged gloves become a vehicle ### Standard precautions because carriage is unknown ### Ventilation controls airborne risk at population level ### Surgical masks for source control and droplets ### Respirators reduce inhalation when fit-tested ### Devices need indication, bundle, removal trigger ### Checklists work only if staff can stop practice ### Sterilise critical, high-level for semicritical ### Clean first: organic matter shields organisms ### Outbreak: confirm excess and case definition #### Genomic match cannot replace epidemiology ## Recovery and the final record ### Recovery is an active phase of care ### Muscle loss, neuropathy, cognition, sleep ### Document source, cultures, resistance, true allergy ### Record source confidence and unexcluded mimics ### Stop acute-only drugs continued by inertia ### Readmission as incomplete recovery