Empiric Antibiotics: Septic Shock

Principles

  • Goal is “the administration of effective IV abx within 1st hour of recognition of septic shock or severe sepsis.” — (grade 1B and 1C, respectively)
  • Initial empiric Rx should include “one or more drugs active against all likely pathogens with adequate penetration into tissues presumed to be source of sepsis.” — (grade 1B)
  • Abx should be “reassessed daily for potential de-escalation.” — (grade 1B)
  • Combination therapy, when used empirically for severe sepsis, should not be continued more than 3-5 days” but de-escalate to single-agent therapy as soon as susceptibilities are known.” — (grade 2B)
  • Source control in first 12 hours if feasible. — (grade 1C)

Empiric Therapy

  • Empiric Rx depends on host factors, recent abx exposure, allergies, clinical syndrome and likely site of infection, local antibiogram and pt’s prior infections or colonization
  • Combination therapy recommended in neutropenics with severe sepsis, those with prior MDR pathogens, and respiratory failure or septic shock patients. — (grade 2B)
  • Practically, this usually means vancomycin + anti-Pseudomonal beta-lactam + either aminoglycoside or anti-Pseudomonal FQ

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Get Fit Week! Ideal Cardiovascular Fitness

Get Fit Week

As our year comes to a close, we would like to present our last themed series of posts, a part of GET FIT WEEK. These posts will focus on the scientific evidence and guidelines for obtaining and mantaining physical fitness, with a focus on health benefits and tools for achieving these goals.

Ideal Cardiovascular Fitness

It makes sense to start with ideal cardiovascular fitness! The American Heart Association 2020 Strategic Goals include this idea. It is defined as optimal levels of three cardiovascular risk factors (blood pressure, fasting glucose, cholersterol) and 4 lifestyle behaviors (BMI, smoking, physical activity, and diet). In a cohort study of ~5800 young adults (age range of 29 to 39 years) from the United States, Finland, and Australia, investigators compared the presence of these 7 measures of ideal cardiovascular fitness with carotid intima-media thickness. The ideal numbers for each metric is as follows: BP 120/80, total cholesterol < 5.17 mmol/L, fasting glucose < 5.6 mmol/L, BMI < 25 kg/m2, and no history of smoking (or quit > 1 year ago). Ideal physical activity was defined as >150 min/week of moderate exertion or > 75 min/week of vigorous exertion. The concept of the ideal diet was most complicated, requiring 4 of the following 5 components: > 4.5 cups of fruits or vegetables per day, > two 3.5 oz servings of fish per week, > three 1 oz servings of whole grains per day, < 1500 mg sodium per day, and < 450 kcal from sugary drinks per week. One of the most notable aspects of this study was that only 1% of the participants had all 7 ideal CV health metrics! The findings of the study indicated that, with the presence of each additional “ideal” measure (i.e. well-controlled BP, recommended levels of physical activity, etc.), carotid intima-media thickness was significantly lower. Essentially, this suggests that physical fitness, as defined by the above measures of blood pressure, cholesterol, BMI, smoking, etc., not only makes you feel great, (and need less medications!), it appears to have a significant impact on the burden of atherosclerotic disease. The authors note that “this finding and the fact that complete ideal CV health was very rare among this large sample of young adults strengthen the need for early evaluation of CV risk factors and for development of effective intervention strategies for behavioral change.” The next question is, does this translate into a mortality benefit. To read the full study, click here.

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Necrotizing Fasciitis 101

General

  • Skin and soft tissue infection that extends to involve the fascia and muscles
  • Often associated with pre-existing skin infection, trauma, chronic ulcers, surgical wounds

Pathegenesis and Risk

  • Pathogens include aerobic and anaerobic bacteria including Group A Streptococcus (GAS, S. pyogenes), Clostridium perfringens, CA-MRSA, Klebsiella spp
  • Patient risk factors: Diabetes, steroids, burns, neutropenia
  • Clostridium septicum – gram positive, spore-forming anaerobe; trauma not needed for infection to occur; associated with GI and hematological malignancies
  • Clostridium causes myonecrosis through release of exotoxins
  • Clinical suspicion is important in guiding management including urgent surgical consultation – mortality ranges from 30-70% and increases with surgical delay

Management

  • Timely surgical exploration is essential to determine the extent of necrosis and debride all necrotic tissue
  • Repeat surgical exploration is typical 24-36 hours later and as needed
  • Empiric broad spectrum antibiotics should be started immediately and cover MRSA, streptococci, gram-negatives, anaerobes and narrow down pending cultures
  • Consider adding clindamycin to regimens if Group A Strep and clostridia species are suspected

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