sepsis and antimcrobial stewardship: are they really
TRANSCRIPT
Sepsis and Antimcrobial Stewardship: Are they
really mutually Exclusive?
DR KATE ADAMS
CONSULTANT INFECTIOUS DISEASES
HULL AND EAST YORKSHIRE NHS TRUST
AMS
Sepsis
No!
At least not if the sepsis programme is run properly………
4 point plan for AMS and Sepsis programme harmony
u Always ensure a good AMS programme is running first
u Make patient safety rather than CQUIN achievement your focus
u Target the right patients
u Target the antibiotics
4 point plan for AMS and Sepsis programme harmony
u Always ensure a good AMS programme is running first
u Make patient safety rather than CQUIN achievement your focus
u Target the right patients
u Target the antibiotics
4 point plan for AMS and Sepsis programme harmony
u Always ensure a good AMS programme is running first
u Make patient safety rather than CQUIN achievement your focus
u Target the right patients
u Target the antibiotics
Point 2: Patient safety rather than CQUIN focus
u Sepsis pathway that combines screening and patient management
u Extensive education programme
u Focus on deteriorating patient rather than just sepsis
Sepsis Pathway
Point 2: The Sepsis 6
u Give oxygen
u Take blood cultures
u Take bloods including a blood for lactate
u Give IV antibiotics
u Give IV fluids
u Take a urine sample and monitor urine output
Point 2: The Sepsis 6
u Give oxygen
u Take blood cultures
u Take bloods including a blood for lactate
u Give IV antibiotics
u Give IV fluids
u Take a urine sample and monitor urine output
u Review and de-escalate
Blood Culture Taking in HEYHT
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
1 2 3 4 5 6 7 8 9 10 11 12
Number of Blood Cultures 2016 / 17
4 point plan for AMS and Sepsis programme harmony
u Always ensure a good AMS programme is running first
u Make patient safety rather than CQUIN achievement your focus
u Target the right patients
u Target the antibiotics
Systemic Inflammatory Response Syndrome (SIRS) ≥2 of following: Temp > 38°C or < 36°C Pulse > 90bpm RR > 20bpm WCC > 12000 or < 4000 / mmᶟ or > 10% band forms Septic Shock
SIRS plus evidence of Infection plus organ dysfunction plus refractory hypotension
Severe Sepsis
SIRS plus evidence of Infection plus organ dysfunction
Sepsis
SIRS plus infection
Mortality 10 – 15%
Mortality 15 – 25%
Mortality 40 – 55%
Systemic Inflammatory Response Syndrome (SIRS) ≥2 of following: Temp > 38°C or < 36°C Pulse > 90bpm RR > 20bpm WCC > 12000 or < 4000 / mmᶟ or > 10% band forms Septic Shock
SIRS plus evidence of Infection plus organ dysfunction plus refractory hypotension
Severe Sepsis
SIRS plus evidence of Infection plus organ dysfunction
Sepsis
SIRS plus infection
Mortality 10 – 15%
Mortality 15 – 25%
Mortality 40 – 55%
Systemic Inflammatory Response Syndrome (SIRS) ≥2 of following: Temp > 38°C or < 36°C Pulse > 90bpm RR > 20bpm WCC > 12000 or < 4000 / mmᶟ or > 10% band forms
Septic Shock Subset of patients with
Sepsis in which particularly profound circulatory,
cellular and metabolic abnormalities substantially
increase mortality
Severe Sepsis
Life threatening organ dysfunction due to a dysregulated host response to infection
Sepsis
SIRS plus infection
Mortality 10 – 15%
Mortality 15 – 25%
Mortality 40– 55%
Infection
Systemic Inflammatory Response Syndrome (SIRS) ≥2 of following: Temp > 38°C or < 36°C Pulse > 90bpm RR > 20bpm WCC > 12000 or < 4000 / mmᶟ or > 10% band forms
Septic Shock Subset of patients with
Sepsis in which particularly profound circulatory,
cellular and metabolic abnormalities substantially
increase mortality
Severe Sepsis
Life threatening organ dysfunction due to a dysregulated host response to infection
Sepsis
SIRS plus infection
Mortality 10 – 15%
Mortality 15 – 25%
Mortality 40– 55%
Infection
Point 3: Target the right patients
u There is time to think and assess properly in the vast majority of patients with infection
u The only evidence for urgent (broad spectrum) antibiotics is in patients with septic shock
Time from onset of hypotension to effective antibiotic therapy
Kumar A et al. Crit Care Med 2006; 34 (6): 1589 - 1596
4 point plan to a good sepsis programme
u Always ensure a good AMS programme is running first
u Make patient safety rather than CQUIN achievement your focus
u Target the right patients
u Target the antibiotics
Point 4: Target the antibiotics
u If you know the source of an infection targeting the common causes of infection in that area is better than giving blind broad spectrum antibiotics
u To do this you need to know the resistance patterns of bacterial isolates in your Trust
u You need strong antibiotic guidelines
HSMR for non obstetric sepsis in HEYHT
Sepsis Team starts
0
10
20
30
40
50
60
70
80
90
100
2014-15 Qtr1
2014-15 Qtr2
2014-15 Qtr3
2014-15 Qtr4
2015-16 Qtr1
2015-16 Qtr2
2015-16 Qtr3
2015-16 Qtr4
2016-17 Qtr1
2016-17 Qtr2
2016-17 Qtr3
2016-17 Qtr4
DDD/1000 Admissions - Agents of Concern
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST Inpatient Antibiotic Usage (DDD/1000 Admissions) (includes In-Patient, Stock items, TTO pre-packs and IDLs. No Out-Patient data included) - Quarterly Report
Piperacillin/Tazobactam and Carbapenems
Quarterly Trends 2014/15 to 2016/17
Piperacillin / Tazobactam Meropenem Ertapenem
Conclusions
u Sepsis programmes can run in harmony with antimicrobial stewardship programmes
u A strong antimicrobial programme must come first
u The sepsis programme needs to be targeted and run by someone that understands infection management
Any Questions?