Transcript Life Threatening Maternal and Perinatal Infections

Life Threatening Maternal
and Perinatal Infections
Medical Legal Issues in Obstetrics Practice
November 19-20, 2009
Ronald S. Gibbs, MD
Professor, Department of Obstetrics and
Gynecology
Associate Dean, Continuing Medical Education
Learning Objectives
At the completion of this presentation, in the
learner’s practice, she/he will
1. Know how to recognize sepsis early in the
course.
2. Know how to institute effective therapy
promptly.
3. Know when surgical intervention is needed.
4. Know how and when to screen for Group B
Streptococci (GBS) among pregnant
women.
5. Know which antibiotics to use for GBS
prophylaxis among women who can not
receive penicillin.
The Obstetrician Gynecologist
and Sepsis
• Most OBGYNs see sepsis infrequently
or rarely.
• Patient survival depends upon early
critical decision making.
• Sepsis/infections are important causes
of death among OBGYN patients.
Causes of Pregnancy-Related Death:
Livebirth in U.S.
Other
11%
Hemorrhage
21%
Anesthesia
3%
Embolism
23%
Cardiomyopathy
6%
PIH
24%
Infection
12%
For Livebirth, N = 797, 1987-1990, Berg et al (CDC), O&G 1996;88:1-7
Pelvic Microbiology
Aerobes
Gram +
Gram -
Anaerobes
Gram +
Others
Gram -
Streptococci
E. Coli
Peptostrep Bacteroides
S. Aureus
Klebsiella
Peptococci Fusobacteria Mycoplasmas
Proteus
Clostridia
Enterobacter
Pseudomonas
Gonococci
Chlamydia
Recent Definitions Describing
Sepsis and Related Conditions
Sepsis
Systemic response to serious infection.
Clinical evidence of infection plus
evidence of systemic response
including tachypnea (>20/min),
tachycardia (>90/min), and/or hyper- or
hypothermia (rectal temperature >38.3C
or <35.6 C).
Manifestations of systemic
inflammatory response syndrome in
association with infection.
From Sweet RL & Gibbs RS "Infectious Diseases of the Female Genital Tract," 5th ed 2009.
Epidemiology of Sepsis, 1979 to
2000, United States
No. of cases (rate) of sepsis,
1979
164,000 (82.7/100,000
population)
No. of cases (rate) of sepsis,
2000
660,000 (240.4/100,000
population)
Average age of cases, yrs.
60.8 ± 12.7
Females
52%
Selected coexisting conditions:
• Pregnancy
• HIV infection
• Cancer
• Diabetes
Martin GS et al. NEJM 2003; 348:1546-54
0.3%
2.0%
14.5%
18.7%
Clinical Manifestation of Sepsis
Temperature instability
Altered sensorium:
Flushing, peripheral
vasodilation
Combativeness,
confusion,
disorientation, impaired
judgment.
Pulmonary:
Cardiac:
ARDS (in 25-50% with
septic shock):
tachypnea, dyspnea,
stridor, cyanosis,
pulmonary edema
Tachycardia
arrhythmia
ischemia, even MI
Clinical Manifestation of Sepsis
Hematologic:
DIC, thrombocytopenia,
spontaneous bleeding.
Abdominal/pelvic:
Intestinal obstruction,
evisceration, jaundice
peritonitis and abscess
Wound:
Renal:
Oliguria, anuria, pyuria
Cellulitis, abscess,
necrotizing fasciitis,
Meleney’s gangrene,
myonecrosis.
Differential Diagnosis of Sepsis
***Hypovolemia
***Hypovolemia
***Hypovolemia
*Pulmonary
Embolism
*Amniotic Fluid
Embolism
*Diabetic
Ketoacidosis
*Cardic Tamponade
*Aortic Dissection
*C. difficile Colitis
*Hemorrhagic
Pancreatitis
*Infected Vascular
Catheter
*Cardiogenic Shock
Management of Sepsis
• Admission to ICU (unless to OR first)
• Support the organ systems
• Eradicate the infection
– Most common avoidable errors leading to
death:
• Failure to use appropriate antibiotic
• Failure to institute appropriate drainage
Evidence-Based Management of
Severe Sepsis and Septic Shock
• Dellinger RP, Levy MM, Carlet JM.
Surviving Sepsis Campaign:
International Guidelines for
Management of Severe Sepsis and
Septic Shock. Crit Care Med
2008;36:296-327.
Evidence-Based Management of
Severe Sepsis and Septic Shock
Initial Resuscitation
• Begin as soon as sepsis is
diagnosed, do not delay pending ICU
admission. During first 6 hours, goals
of therapy should include all of the
following:
–CVP: 8 to 12 mm Hg
–Mean arterial pressure: ≥65 mm Hg
–Urine output: >0.5mL/kg/hr
–Central venous or mixed venous oxygen
saturation ≥ 70% or ≥65%, respectively.
Grade
1C
Evidence-Based Management of
Severe Sepsis and Septic Shock
Diagnosis
•Obtain appropriate cultures
including at least two blood
cultures and obtain culture of
other appropriate sites before
antibiotic therapy is initiated.
• Perform other diagnostic
studies such as imaging
studies.
1C
1C
Evidence-Based Management of
Severe Sepsis and Septic Shock
Antibiotic Therapy
• Begin IV antibiotic therapy within one hour of
recognition of severe sepsis and septic shock
after appropriate cultures have been obtained.
• Initial therapy should include one or more
antibiotics that have activity against the likely
pathogens and that penetrate into the presumed
source of infection.
• Reassess antibiotic regimen after 48-72 hours
to prevent development of resistance, reduce
toxicity and reduce costs.
1D/1B
1C
1C
Evidence-Based Management of
Severe Sepsis and Septic Shock
Source Control
• Make a specific diagnosis as rapidly as
possible.
• Evaluate patient for “source control” by, for
example, drainage of an abscess, debridement
of necrotic tissue (such as by hysterectomy)
• Use the effective intervention associated with
the least physical insult (e.g. percutaneous
rather than surgical drainage).
• Remove infected device.
1C
1C
1D
1C
Evidence-Based Management of
Severe Sepsis and Septic Shock
Fluid Therapy
See Initial Resuscitation
• Give either natural or artificial colloids or
crystalloids; there is no evidence-based
support for one fluid versus another.
• Give fluid challenge in patients with
suspected of hypovolemia at a rate of ≥1000
mL of crystalloids or 300 to 500mL of colloids
over 30 minutes. More rapid
administration/greater amounts may be
needed.
1B
1D
Evidence-Based Management of
Severe Sepsis and Septic Shock
Vasopressors
• Maintain MAP ≥65 mmHg. When an
appropriate fluid challenge fails to establish
blood pressure and organ perfusion, give
vasopressor agents. These vasopressors may
also be needed transiently to sustain life in the
setting of life-threatening hypotension, even
when a fluid challenge is in progress and
hypovolemia has not yet been corrected.
• Either norepinephrine or dopamine (through
central catheter as soon as available) is the
first choice vasopressor agent to correct
hypotension in septic shock. Epi, phenylephrine, or vasopressin not first line.
1C
1C
Evidence-Based Management of
Severe Sepsis and Septic Shock
Steroids
• IV hydrocortisone should be given only
to adult septic shock patients after it
has been confirmed that their blood
pressure is poorly responsive to fluid
resuscitation and vasopressor therapy.
• ACTH stimulation test not be used to
identify the subset of adults with septic
shock who should receive
hydrocortisone.
2C
2B
Evidence-Based Management of
Severe Sepsis and Septic Shock
Blood Product Administration
• Once tissue hypoperfusion has been resolved
and in the absence of extenuating
circumstances, such as significant coronary
artery disease, acute hemorrhage, or lactic
acidosis, red blood cell transfusion should
occur only when hemoglobin decreases to <7.0
g/dL to target a hemoglobin of 7.0 to 9.0 g/dL.
• Erythropoietin is not recommended as a
specific treatment of anemia associated with
sepsis. In patients with severe sepsis, platelets
should be administered when counts are less
than 5,000/mm3 regardless of apparent
bleeding.
1B
1B
Evidence-Based Management of
Severe Sepsis and Septic Shock
Deep Vein Thrombosis
• Patients with severe sepsis should receive DVT
prophylaxis with either unfractionated heparin or
low molecular weight heparin. If there is a
contradiction to heparin use (such as active
bleeding, thrombocytopenia or severe
coagulopathy), use graduated compression
stockings or intermittent compression device. In
very high risk patients (e.g., severe sepsis plus a
history of DVT), a combination of drug and
mechanical therapy is recommended.
• In high risk patients LMWH is preferred.
1A
2C
Evidence-Based Management of
Severe Sepsis and Septic Shock
Other recommendations for ICU care
• Ionotrope Therapy
• Recombinant Human Activated Protein C
• Mechanical Ventilation
• Bicarbonate Therapy
• Sedation, analgesia, neuromuscular blockade.
• Glucose control
• Renal replacement
Management of Sepsis: Surgical
Eradication of Infection
This is the critical decision of the
obstetrician gynecologist:
• When to operate and
• What procedure to do.
2002 GBS Prevention Guidelines
• Recommend screen based approach
only.
• Change alternative antibiotics for
penicillin allergic patients.
• More specific recommendations for
clinical scenarios.
2002 GBS Screen Based
Approach
1. All pregnant women should be
screened at 35-37 weeks’ gestation for
vaginorectal GBS colonization. At
time of labor or ROM, intrapartum
chemoprophylaxis (IPC) should be
given to pregnant women identified as
GBS carriers. (A-II)
2002 GBS Screen Based
Approach
4. If result of GBS culture not known at
time of labor, give IPC if:
– < 37 weeks’ gestation or
– ROM  18 hours or
– T  100.4F ( 38.0C) (A-II)
2002 GBS Screen Based
Guidelines
6. Specimen Collection
–
–
–
–
–
Distal vagina and anorectum
Collected by patient or provider (B-II)
No speculum
Transport medium acceptable
Label “GBS culture”
2002 GBS Screen Based
Approach
6. Laboratory Processing
– Inoculate into selective broth medium.
(eg LIM or Trans-Vag) (A-II)
– Methods provided for susceptibility to
clinda/erythro for GBS from
penicillin allergic women.
– Labs “should report results to site of
delivery and provider.”
2002 GBS Screen Based
Approach
7. Inform patients of results and
recommended intervention.
– In absence of GBS bacteriuria, do not
treat GBS genital colonization before
intrapartum period. (D-I)
2002 GBS Screen Based
Guidelines
9. Penicillin G: Drug of choice.
– Ampicillin: Alternative.
– For penicillin allergy:
•
Clindamycin/erythromycin no longer drugs of
choice.
2002 GBS Screen Based
Guidelines
10. Patients with PCN allergy, not at high
risk for anaphylaxis:
– Cefazolin, 2gm IV then 1gm every 8 hours
until delivery. (B-III)
2002 GBS Screen Based
Guidelines
10.Patients with PCN allergy at high risk
for anaphylaxis:
– GBS susceptible:
Clinda, 900 mg IV q 8h
OR Erythro, 500 mg IV q 6h
– GBS resistant to Clinda or Erythro or
unknown susceptibility:
Vancomycin, 1 gm IV q 12h (C-III)
2002 GBS Guidelines- CDC
Summary: If GBS isolate is resistant
to EITHER erythromycin OR
clindamycin and patient has high risk
allergy to penicillin, then use
vancomycin.
MMWR February 2009
CDC Guidelines on GBS
Possible Changes in 2010
• Recommendations of antibiotic
selection in patients who cannot take
penicillin.
• Dose of penicillin.
• Management of premature rupture of
membranes.
• Others.
References
1.
2.
3.
4.
Sweet RL & Gibbs RS “Infectious Diseases of the
Female Genital Tract,” 5th ed 2009.
Martin GS et al, The epidemiology of sepsis in the
United States from 1979 through 2000. NEJM 2003;
348:1546-54
Dellinger RP, Carlet JM, et al. Surviving Sepsis
Campaign International Guidelines for
Management of Severe Sepsis and Septic Shock
2008. Crit Care Med 2008;36:296-327.
CDC. Prevention of Perinatal Group B
Streptococcal Disease, Revised Guidelines from
CDC, MMWR 2002; 51 (No. RR-11): 1-24.