TREATING SEPSIS

A 43 year old lady with short bowel syndrome following surgery for Crohn’s disease, on home TPN, is admitted with hypoxemia, tachycardia, pyrexia and neutropenia. Presumed diagnosis  - infected intravenous catheter (line sepsis).

A 54 year old male develops a fever, leucocytosis and inflammation around his midline sternotomy site 5 days after undergoing coronary bypass surgery. Presumed diagnosis – wound infection, possible mediastinitis.

There is a strong possibility of infection in both of these cases with staphylococci, coagulase-positive or negative.

Vancomycin should be added to, for example, piperacillin+azobactam. Once the infecting organisms have been isolated, the spectrum of antimicrobials should be narrowed (if methacillin resistant staph aureus –MRSA- is isolated, the piperacillin+ azobactam should be discontinued).

Vancomycin + Piperacillin+Tazobactam or Ciprofloxacin.

The lady with Crohn’s disease and presumed line sepsis does not respond to line removal and the antibiotic regimen above, blood cultures come back positive for unspeciated candida. Confirmed diagnosis – fungal sepsis.

Candida albicans, tropicalis and parapsilosis are usually (but not always) sensitive to fluconazole, candida glabrata and krusei are not. All are sensitive to amphoteracin. The options are 1) start high dose fluconazole and if there is no response move over to the more toxic agent, amphoteracin, 2) start amphoteracin immediately. In this patient’s case, she is severely ill, and has depleted physiologic reserve and may well be immunocompromised (steroids), I would start amphoteracin B. If there is a question of renal insufficiency, I would prescribe the less toxic colloidal or liposomal form.

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