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% Embolism 23% Anesthesia 3% Cardiomyopathy 6% Infection 12% PIH 24% For Livebirth, N = 797, 1987-1990, Berg et al (CDC), O&G 1996;88:1-7

Pelvic Microbiology

Aerobes Gram + Streptococci Gram E. Coli Anaerobes Gram + Gram Peptostrep Bacteroides Others Chlamydia S. Aureus Klebsiella Proteus Enterobacter Pseudomonas Gonococci Peptococci Fusobacteria Mycoplasmas Clostridia

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 No. of cases (rate) of sepsis, 2000 Average age of cases, yrs.

164,000 (82.7/100,000 population) 660,000 (240.4/100,000 population) 60.8 ± 12.7

Females 52% Selected coexisting conditions:

•

Pregnancy

•

HIV infection

•

Cancer

•

Diabetes 0.3% 2.0% 14.5% 18.7% Martin GS et al. NEJM 2003; 348:1546-54

Clinical Manifestation of Sepsis

Temperature instability Flushing, peripheral vasodilation Altered sensorium: Combativeness, confusion, disorientation, impaired judgment.

Pulmonary: ARDS (in 25-50% with septic shock): tachypnea, dyspnea, stridor, cyanosis, pulmonary edema Cardiac: Tachycardia arrhythmia ischemia, even MI

Clinical Manifestation of Sepsis

Hematologic: DIC, thrombocytopenia, spontaneous bleeding.

Abdominal/pelvic: Intestinal obstruction, evisceration, jaundice peritonitis and abscess Renal: Oliguria, anuria, pyuria Wound: 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, phenyl ephrine, 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/mm 3 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,” 5 th 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.