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?