INFECTION CONTROL
last couple of weeks, how many of you will have seen patients for whom the initial antimicrobial therapy was ineffective? If we don’t have effective antimicrobials, I don’t think we’re going to see an extra 10 million lives lost every year; we’re going to see an extra 38 million – because we won’t be able to treat people with sepsis as the final common pathway to death from most infectious diseases worldwide,” he warned.
Sepsis Six
He went on to discuss changes to the guidance on the Sepsis Six and the management of suspected sepsis in patients presenting at hospital. The Academy of Medical Royal Colleges new guidance proposes that patients with suspected sepsis should be assessed via an updated National Early Warning Score, which assigns a score to a patient’s vital signs, and provides an overall number that determines the speed and seniority of clinical response.
The new guidance aims to empower
healthcare professionals to recognise and treat the very sickest people with sepsis immediately (within one hour) and assess and treat those who are less ill within three hours.5
The extended time
for investigation of those who are less sick aims to enable the medical team to accurately identify the source of infection and prescribe the correct antibiotic – reducing the risk of antibiotic overuse and subsequent AMR.3
In line with the new guidance, the UK Sepsis Trust has updated its clinical material, which includes screening and action tools.5
Dr Daniels discussed the
latest version of the Sepsis Six (Fig 1): this emphasis the need to ensure a senior clinician attends to look for sepsis, as well as conditions that may mimic sepsis. They are required to “put the brakes on broad-spectrum antimicrobial therapy”, if appropriate, but they also need to smooth the process of care for people with complicated infections – for example, those who might be amenable to source control.
Step 2 is to correct hypoxia; step 3 is to obtain a full set of bloods and cultures; step 4 is to give intravenous (iv) antibiotics – which remains unchanged, apart from the addition of ‘considering source control’. Step 5 is to give iv fluids; and step 6 is to continue monitoring. Dr Daniels explained that the Sepsis Six tool invites the clinician to record their reasons for variance from the protocol. “If you suspect pancreatitis because they have gallstones and decide to withhold antimicrobials until you know a bit more, that’s sensible medicine. It should count as compliance with the pathway. It is
24 Fig 1. The new version of the Sepsis Six.
important that whatever system you have allows for clinical judgement. It is intended to empower not to dictate therapy,” he commented. He went on to highlight some of the challenges facing the NHS and the need for improvement: “The NHS standards say that every patient who is admitted as an emergency should be seen by a suitable consultant within 14 hours, but we do not do it. In the East of England you have a one in eight chance. We cannot mobilise senior clinicians as quickly as we would want to, however much we believe it is the right thing to do. This is why we need these empowering prompts,” he asserted.
Sepsis management Dr Daniels went on to discuss the Surviving Sepsis Campaign’s international guidelines6
for management of sepsis
and septic shock, published in October 2021, which introduced two key changes: the first was the recommendation against using qSOFA compared to SIRS, NEWS or MEWS as a single screening tool for sepsis or septic shock. He commented that the guidelines were “the most credible set of guidelines available”, and we must change this practice now. Secondly, in terms of antibiotic timing, the guidance now adopts a ‘two-tier’ approach. If the patient has shock, or if the diagnosis of sepsis is very probable or certain, then the recommendation to give antimicrobials within one hour remains. However, it is recognised that the evidence around one hour being ‘a magic time’ is somewhat ‘scant’. Therefore, for people who have a slightly softer diagnosis, (ie it might be pancreatitis/ gastroenteritis with pre-renal failure as a consequence), the guidance now advises
SEPTEMBER 2022
WWW.PATHOLOGYINPRACTICE.COM
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64
