Sepsis from a microbiological perspective Veronika Holá Institute for Microbiology Faculty of Medicine, Masaryk University  and St. Anne´s Faculty Hospital in Brno TZKM, spring 2018 Sepsis • Definition od sepsis • Septic haemodynamic • Presence of infection • SIRS • Systemic Inflammatory Response Syndrome (SIRS) • Sepsis = SIRS + infection • Severe sepsis = sepssis + signs of organ dysfunction • Septic shock = severe sepsis + haemodynamic changes Response of the macroorganism Infection, SIRS, sepsis Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., Schein, R., et al. (1992). Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest, 101(6), 1644–1655. Sepsis • Cytokine storm • Systemic Inflammatory Response Syndrome (SIRS) • Reaction of immune system to microbial products  • SIRS include – 1) Body temperature <36 °C or >38 °C  – 2) Heart rate greater than 90 beats per minute – 3) Tachypnea (high respiratory rate), >20 breaths per minute  or arterial partial pressure of carbon dioxide <4.3 kPa (32 mmHg) – 4) White blood cell count <4000 cells/mm³ (4 x 109 cells/L) or >12,000  cells/mm³ (12 x 109 cells/L) or the presence of >10% immature neutrophils (band forms) ‐ "left‐shift" • The septic patients meet criteria for SIRS • Clinical symptoms – Temperature – Respiratory rate – Pulse rate – Nausea – Confusion – Blood pressure – Urine secretion • + Laboratory markers – Number of leukocytes – Haemocoagulation – Respiratory‐metabolical acidosis – Organ dysfunction – Inflammatory markers Bedside dg. of sepsis SIRS criteria x SOFA score x qSOFA score • SOFA score ‐ Sequential organ failure assessment  score • Based on six different scores – Respiratory, cardiovascular, hepatic, coagulation, renal and  neurological systems • qSOFA ‐ simplified – Low blood pressure (SBP ≤ 100 mmHg) – High respiratory rate (≥ 22 breaths/min) – Altered mentation (GCS < 15) Sepsis vs. microbaemia Bacteriaemia  !!! Starting sepsis  Interaction with immunity system  Cytokines  endothelium of capillars + inflammation  Systemic Inflammatory Response Syndrome (SIRS) + Compensatory Anti‐inflammatory Response Syndrome (CARS) Sepsis vs. microbaemia • Sepsis x bacteraemia and bacteraemia x sepsis • Blood normally sterile  • Not necessarily present in developed sepsis  • High risk of multi‐organ failure • Sepsis ‐ mortality • Septic shock The phases of the development of  the generalized infection  Recovery Lethal result Chronic sepsis 1. 2. 3. 4. 5. Syndrome of the systemic  inflammatory answer Purulent resorptive fever Local inflectional focus SepticopyemiaSepticemia • Microbial process • Necessary conditions • Most bacteria – only in attenuated patient Pathogenesis of sepsis http://faculty.washington.edu/alexbert/MEDEX/ • Clinical symptoms • Pathological physiology – Local x generalized inflammation • Laboratory markers www.nzma.org.nz • Lungs • Kidneys • Heart • Livers • Intestine • Brain • Adrenals • Pancreas (B‐cells) • Coagulation system (DIC) • Leukocytes (PMNs) Organ dysfunction in sepsis Therapy of sepsis • Intensive • Complex • ATB treatment not satisfactory • Need of shock treatment • Event. surgical intervention Spectrum of etiological agents of sepses • Autumn 2017 lecture – Sepsis in localised infections – Wound sepsis – Fulminant sepsis – Urosepsis – Intraabdominal sepsis – Nosocomial sepsis – Sepsis puerperalis – Newborn sepsis – Blood stream infections • Catheter‐related BSI & sepsis Catheter related sepsis • Catheter‐related blood stream infection • Colonisation of catheter • Suspect catheter‐associated infection • Local infection of catheter Catheter related sepsis • Peripheral venous catheters • Peripheral arterial catheters • Schwan‐Ganz catheters • Central venous catheters (CVC) • Tunnelised CVC • Implanted venous ports Venous catheters • Infection • Extraluminar • Intraluminar • Source of the infection Infection of the catheter Infection of the catheter • Catheter sepsis • Trombophlebitis • Central sepsis – Endarteritis and (trombo‐)phlebitis – Endocarditis • Accute endocarditis • Subaccute and chronic endocarditis  sepsis lenta  • „Culture‐negative“ endocarditis BSI related sepsis CoNS Enterobacteria PSSP STAU ECSP & SRSP yeasts Other (Sherertz et al. , 1990) (Wisplinghoff et al., 2004 ) Etiology of CRBSI I. • Biofilm & Resistance G+ 60-70% CoNS S. aureus Enterococci and streptococci G- Enterobacteria Pseudomonas, Burkholderia, Stenotrophomonas, aj. Yeasts Other MRSA EARSS Annual Report 2014 VRE E. faecium Karbapenemases K. pneumoniae ? • Specifity of the examination Etiology of CRBSI II. Karbapenemases P. aeruginosa MDR (FQ, AMG, CEF III.) K. pneumoniae PREVENTION OF CATHETER-RELATED INFECTIONS IS PREFERABLE TO TREATMENT • Aseptic character of catheter insertion +  • Expirienced personnel +  • High‐quality subsequent care • Place of the catheter insertion • No. of catheter lumen • Surface treatment of the entry • Better connection systems and in‐line filtration • Implanted ports and tunnelisation Prevention of CRBSI – catheter insertion • Aseptic manipulation • Expirienced personnel • Care management • Minimalisation of manipulation • Regular control • Treatment of site of insertion by disinfectants  No ATB oitments • Prophylactic administration of anticoagulants  No systemic prophylaxis with ATB • Regular exchange of short‐term catheters  No preventive exchange of long‐term catheters (CVC) • Regular exchange of infusion sets and accessories Prevention of CRBSI – catheter care • Material • Surface treatment • Impregnation of catheter by antimicrobial compounds Prevention of CRBSI – catheter • Impregnation with antiseptics • Impregnation with ATB • Impregnation with Ag • Other chemicals used for catheter surface impregantion (in vitro) Prevention of CRBSI – catheter • Rapidity • Sensitivity • Specifity  • Correct sampling technique Microbiological dg. of sepsis • Diagnosis of catheter sepsis – Positive quantitative culture of extracted catheter – Positive haemoculture – Sepsis without response to ATB therapy, positive  response to the catheter extraction Catheter sepsis Haemoculture sampling • Patient with suspiction of bacterial infection – CRP > 60 mg/l – Fever in anamnesis – (Inserted catheters) • Aseptic sampling • 2‐3 haemoculture bottles • 30‐60 min. intervals • Before ATB treatment • If treated, sample prior to next ATB dose Haemoculture sampling • Skin disinfection – 0,5% chlorhexidine in 70% alcohol – Polyvinylpyrolidon w. 10% of iodine – Iodine tincture – 70% alcohol • Change of needle • Disinfection of bottle end‐seal Bruker Daltonics textbookofbacteriology.net PCR – quantification Broad range PCR  assay FISH (Fluorescent in situ hybridisation) etc. ID  (60 min) www.aquilantscientific.ie Culture (up to 7 days) „Genetics“(cca 37 hod.) Sequenace PCR identification Typing (MLAST, PFGE…) etc. ID     (hrs‐days) Rapidity + sensitivity + specifity ID     (hrs‐days) Haemoculture examination Haemoculture examination • Positivity • Length of culture – HACEK  – Fungaemia • TTD  • No of anaerobic BSI very low • Serology • Biochemistry • MALDI from sample Other possibilitieas of sepsis diagnostic A) Catheter in situ • Quantification of haemocultures • Quantity of microbes in catheter sample • Comparison of microbial quantity in samples from periphery and from catheter • Difference in TTD in haemocultures from periphery and from catheter • Intraluminar brush • AOLC (Acridine Orange Leukocyte Cytospin)  Proof of catheter colonisation B) Extracted catheter • Sonication, vortexing • Semiquantitative method • Intraluminar flush • Subculture + subsequent inoculation • Catheter staining Proof of catheter colonisation • 80% of primary bacteraemia CVCs • CoNS • STAU  • ECSP & CASP  • Catheter infection – Extraluminar – Haematogenic infection – Endoluminar Interpretation of positive results Interpretation of positive results • Depends on the species of isolated microbe • Obligate pathogens • Typical nosocomial pathogens of BSI • Saprophytic microbes Therapy of CRBSI Retaining of infected catheter Less serious CRBSI Stabilised patient Reaction on ATB therapy Attempt at eradication of biofilm Elimination of focus +  ATB • Systemic ATB treatment  Fails in eradication of biofilm layer • ATB with higher anti‐biofilm effect • Advantage to combiate ATBs • Antimicrobial lock ATB therapy of CRBSI Chance of ATBs to affect infectious process Focal infections MODS multiple organ dysfunction syndrome Sepsis Septic shock Bacteriaemia & fungaemia ATB M O R T A L I T Y ATB ATB Treatment of the sepsis • Control the infection – Elimination of CA  – Finding the focus and surgical intervention – Removal of cause of septic state • Symptomacic therapy – Breething support  – Adjustment of haemodynamic – Support for failing organs – Continuous veno‐venous hemodiafiltration – In DIC (disseminated intravascular coagulation)