TREATING SEPSIS

A 48 year old intellectually subnormal lady is admitted with red hot indurated skin over her left buttock. Presumed diagnosis – cellulitis.

The most likely organisms are streptococci and staphylococci, if community acquired then cloxicillin is adequate, again this patient was institutionalized, and must be treated as hospital acquired:

Vancomycin + gentamycin.

The patient becomes progressively stuperose and hypotensive as the day goes on. She is intubated and CT of her pelvis reveals gas in the muscles and along the fascial planes of her left buttock. Confirmed diagnosis – necrotizing fasciitis.

This patient requires immediate surgical intervention and debridement of necrotic tissue. The infection has probably arisen from an ischio-rectal abscess and is polymicrobial in nature: Streptococci, Staphylococci, Bacteroides, Clostridium (1).

Penicillin (high dose) or ciprofloxacin (if penicllin allergic) + clindamycin

On the 8^th day following admission, this patient is extubated. Four hours later she becomes severely dyspneic and hypoxemic. She is reintubated and chest x-ray reveals a new infiltrate in her left base. Presumed diagnosis – aspiration pneumonitis.

In most cases, aspiration events are sterile, and antimicrobials are unnecessary (2). In the case of patients already in intensive care, however, nasopharyngeal colonization with gram negative organisms has occurred, and aspiration of infected material should be presumed, Although it has been conventional to treat these patients with anti-anaerobe coverage, it is unlikely that this is necessary (3).

Add ampicillin+sulbactam or piperacillin+tazobactam

References

(1)   Hill MK, Sanders CV. Skin and soft tissue infections in critical care. Crit Care Clin 1998; 14(2):251-262.

(2)   Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001; 344(9):665-671.

(3)   Marik PE, Careau P. The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study. Chest 1999; 115(1):178-183.

Copyright 2002 All rights reserved