Sepsis Infection :

The Appropriate Antibiotics

Dr. Veronica Wiwing, SpMK

Introduction
Causes of death (RSCM, 2010)
1)
2)
3)
4)
5)

SIRS & MODS

Inhalation Injury
Shock
ARDS
Sepsis

47.05%
39.70%
30.90%
26.5
23.5%

Introduction
Sepsis @ causa Infection

1)

Contributing factors
a)
b)

2)

Predisposing:
Precipitating: Immunocompromise

Port dentree
a)
b)
c)

Wound infection
Bacterial translocation
Instrumentation

The concept of SIRS & MODS

Infection
Bacterimia
Viremia
Parasytemia
Fungemia

Sepsis

Trauma
Burn

SIRS
Ischemia
Pancreatitis

Diagram: the concept of SIRS and sepsis

Baue, AE, Faist, E, Fry, ED. Multiple organ failure, pathophysiology, prevention, and therapy. New York : Springer, 2000.

The concept of SIRS & MODS

SIRS
systemic Inflammatory response syndrome

Sepsis
SIRS due to objective (laboratory evidenced)
of infection: bacteremia (toxemia)

MODS
multi system organ dysfunction syndrome
(previously: multiple organ failure)
2 or more organs involved
Baue, AE, Faist, E, Fry, ED. Multiple organ failure, pathophysiology, prevention, and therapy. New York : Springer, 2000.

The concept of SIRS & MODS

Shock
lack of perfusion

Septic shock
sepsis with hypotension despite adequate
fluid resuscitation

Severe Sepsis
sepsis associated with organ dysfunction

Baue, AE, Faist, E, Fry, ED. Multiple organ failure, pathophysiology, prevention, and therapy. New York : Springer, 2000.

Predisposing

Local effect of Pro

Inflammatory response

Local effect of Anti

Inflammatory response

Precipitating

Pro Inflammatory response

enter the systemic circulation

Systemic Response
SIRS
CARS
MARS

Anti Inflammatory response

enter the systemic circulation

Apoptosis

Organ
dysfunction

immune
Suppression

Equal CARS-SIRS

SIRS Predominant

SIRS Predominant

CARS Dominant

Cardiovascular
compromised

Homeostasis

SIRS Predominant

CARS Compensatory Anti-inflammatory Response Syndrome

MARS Mixed Antagonistic Response Syndrome

Diagram the cascade of SIRS

The concept of SIRS & MODS

Immune response to injury

Tissue injury

SIRS

Exaggerated response

CARS
(ARDS)
immunosuppressive

pro-inflammatory

anti-inflammatory
compensation
3-5 days

recruitment neutrophil
arachidonic acid production
free radicals

5-21 days

The diagram of the nature of SIRS

with the host immune response to injury point of view

time
32 days

The concept of SIRS & MODS

Predisposing factors:
Host / Injury ex : burns devastating injury /
Management (early, advanced)
Precipitating factors (Initiation):
Epithelial damage:
Endothelial (capillary permeability)
Mucosa (disrupted airway mucosa, gut mucosal
disruption, acute tubular necrosis, etc)
Skin-soft tissue necrosis: eschar

Infection @ causa burns injury

Epithelial damage

Host defence
Immunosuppresion

Port dentre:
Wound infection
Bacterial translocation
Instrumentation

Defence aggressor homeostasis

Bacterial Translocation
Splanchnic hypoperfusion lead to ischaemic and
mucosal disruption (epithelial damage)
Altered gut mucosal and intraluminal environment due
to:
Fasting the injured pts
The use of Antacids
The use of certain Antimicrobial

Instrumentation
Disobeyed a and antiseptic handling in procedure of
insertion and maintenance of:
Endotracheal tube, tracheostomy tube, suction catheter,
etc
IV lines, CVP lines, syringes
Indwelling catheter
Wound management

Wound infection
Non vital tissue (eschar)
Tissue perfusion
Wound degradation

Pro-inflammatory Mediators
Immune system suppression

Microorganism: >105/mm3, virulence

The management

In dealing with SIRS, sepsis and MODS, the treatment

should be:
1. Prevention the development
2. Breaking the cascade
The strategy
Listen to what the cells say

The management
Bacterial translocation
The fluid resuscitation:
Adequate volume replacement regarding ischaemic
time (gut mocosa: 4 hrs)
Peripheral vasodilator (low dose dopamine)
Gut resuscitation:
No fasting but early enteral nutrition (when the gut
works: use it! to feed the gut rather than to feed the
body)
No antacids and H2 antagonist
No local antibiotics, no an-aerob antibiotics
No prophylactic antibiotic is needed

The management
Instrumentation
Aseptic procedure supported with appropriate antiseptic
Everything is single use only
No prophylactic antibiotic is needed

The management
Wound infection
Wound cleaning with dressing
moist dressing for 48 hrs (prevent the wound
degradation)
Early excision:
Tangential excision (necrotomy) followed by
(immediate) skin grafting

The management
Wound infection (cont)
Problems:

Haemodynamic stability
Limitations:
Manpower (skill), Facilities, donor
Impending SIRS & MODS
The needs for supportive antibiotics

The use of antimicrobial

The rational use of antibiotics:
Standard
Guidelines
Options

: class I level of evidence

: class II level of evidence
: class III level of evidence

The use of antimicrobial

Guidelines
Systemic and topical antibiotics:
Immune-compromize
Second phase

Shock phase

48hr

Sterile wound

5 - 7 day

Gram positive mo
The wound colonization

Gram negative mo

The use of antimicrobial

Guidelines
Systemic and topical antibiotics should be avoided :

Antibiotic which is cyto-toxic (visceral organs and

wounds)
Antibiotic interfering the gut normal flora balance.
Potent antibiotic killing commensal non patogen
bacteria.
Refer to general guidelines.

Wound
sepsis

Common pathogen:
Streptococcus
pyogenes
Enterobacter sp
Staphylococcus
aureus
Pseudomonas
aurugenosa
Enterococcus sp
Aeromonas

Vancomycin
&
Amikacin
&
Piperacillin or
Ceftazidim
or
Meropenem (single)
Imipenem (single)

1g IV bid
10mg/kg IV initial,
7.5mg/kg IV bid
4g IV qid
500mg-2g IV 8-12hr
500mg-1g IV tid
500mg-1g tid-qid

Burns

Cellulitis

Common pathogen:

Streptococcus sp

Topical antibiotics with oral:

Silver nitrate 0.5%
Moist dressing 2hr
Mafenide acetate cr
apply 2-3 times/day
Silver sulfadiazine 1%cr apply 2-3 times/day
Fusidic acid 2% cr/oint apply 2 times/day
Mupirocin 2% cr
apply 2 times/day
Penicillins:
Penicillin V
1-2g/day PO devided
dose qid
Penicillin G 2-3 MU IV / 4hr
Macrolides:
Erythromycin
1-2g/day PO devided
dose qid

Amos F, Grochowski J, Tongol MAS. MIMS antimicrobial guides Indonesia.

Singapore: MediMedia Asia. PTE.Ltd.; I(1); 2002

The use of antimicrobial

Guidelines
Systemic antibiotics:
48hr

5 - 7 day

Penicillin (V or G)
Penicillinase resistant

No antibiotics

According to mo
succeptibility

Vancomycin
Avoids:
Carbapenem
Imipenem
Aminoglycosides

Sterile wound

Gram positive mo

Gram negative mo

Conclusion(s)
Guideline for using antibiotic in burns
Effectiveness, non toxic to visceral organs as well as
wound
No ideal antibiotic
The use of antibiotic
is a kind of supportive treatment; accomplishment of
treatment sequence
refer to: 1) indication, 2) timing, & 3) clinical condition
supported by a wound biopsy (culture & resistance,
histopathology exam)
should be individual and very selective
Use your judgment

How to manage
this Infection ??
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