Page 31 - 2020 JSOM Winter

• Temperature of >38°C/100.4°F or < 36°C/96.8°F prior exposure to the infection, malaria can be rapidly fatal in
• Cool skin, cyanosis, delayed capillary refill time (>3 the absence of early and specific therapy. 13
seconds)
• Abnormal vital signs, particularly tachycardia (>90 A significant minority of sepsis cases (up to 15%) are due to
bpm), sustained hypotension (systolic blood pressure fungal infections. Candida species are normal flora in the hu-
<90mmHg), tachypnea (>20/min) man gut and vaginal canal and are the most common causes
• Low urine output (oliguria) of fungal sepsis, followed by invasive mold infections such
• Altered or worsening mental status (confusion, lethargy) as Aspergillus and by endemic fungi causing community-
• Rash, purpura (meningococcemia, Rocky Mountain acquired disease, including Histoplasma, Coccidioides, and
spotted fever, other rare etiologies) Talaromyces. In the PFC environment, Candida infections
• Meets the SIRS Criteria; qSOFA criteria and/or high may follow penetrating abdominal trauma with perforation
NEWS2 score (see above) of the gut, while invasive molds may arise after blast injuries
• Lab specific values (See Appendix B.) with devitalized tissue (such as after a high lower extremity
amputation). Therapeutic options for both of these scenarios
NOTE: Typical symptoms may not be present in some patient are very limited in a PFC setting.
populations. Signs of sepsis may be attenuated and/or muted
in the elderly, delayed manifestation in the very young, or Because war wounds are considered grossly contaminated
masked in pregnancy due to the normal physiologic changes wounds, they must be attended to meticulously. Unattended
and absence of a febrile response in up to 50% of pregnant wounds can lead to acute infection and sepsis within days
patients. (or possibly within hours for very large and contaminated
wounds). Quality wound care is essential to infection and
14
Source Identification sepsis prevention as detailed in the JTS Acute Traumatic Wound
Management in the Prolonged Field Care Setting CPG. 15
GOAL: Locate probable cause of infection to most appropri-
ately address the source.
Treatment
Approach to Source Identification: ANTIMICROBIAL THERAPY
• Gather a complete patient history of recent and/or on- GOAL: Use targeted and most appropriate antibiotic therapy
going illnesses. when possible.
• Conduct a thorough head-to-toe exam to look for evi-
dence of infection—wounds, bites, etc. Be sure to exam- Antibiotic regimens: See the JTS Acute Traumatic Wound
ine the genitourinary and perirectal areas, as these are Management in the Prolonged Field Care Setting CPG.
common sites of missed infections. • Minimum: Moxifloxacin 400mg PO daily (or levofloxa-
• Perform rapid malaria, dengue, and point of care source cin 750mg PO daily to provide better coverage of bacte-
tests if in an endemic area, as well as urine dipstick and ria found in wet terrain/jungle environment).
i-STAT labs. 9 • Better: Ertapenem (Invanz) 1g IV/IO once per day (every
24 hours) given over 5 to 10 minutes or IM (not pre-
Sepsis may be of bacterial, fungal, viral, or parasitic origin. ferred), OR ceftriaxone (Rocephin) 2g IV/IO given over
Bacterial infections are the most common causes of sepsis 10 minutes every 24 hours.
followed by parasitic (mainly malaria), viral (e.g., dengue, • Best: Ceftriaxone (Rocephin) 2g IV/IO every 24 hours
influenza, COVID-19), and, finally, fungal diseases. The given over 30 minutes, PLUS vancomycin (Vancocin)
10
prevalence of each is directly related to a given region. Iden- 1.5mg/kg IV/IO every 12 hours (given after ceftriaxone,
11
tifying the cause of sepsis is challenging in the PFC environ- given over 2 hours) PLUS metronidazole (Flagyl) 500mg
ment where advanced diagnostic tests are unavailable, and IV/PO/IO q8hrs, given over 1 hour.
antiviral and antifungal therapies are rarely available. This
CPG focuses on the most common etiologies of sepsis, and the ANTIPARASITIC REGIMENS
treatments of those forms of sepsis that the austere provider If sepsis is suspected in a malaria-endemic area and there is no
can reasonably manage. Advanced preparation is important, other clearly identified source, conduct a malaria point-of-care
and a medical area study and/or medical threat-model analysis test (BINAX Now and thick and thin smears), if available. If
®
should be done prior to traveling to gather data on microbes positive, administer both antibiotics and antimalarials. If unable
specific to that given region. to test for malaria, empiric antimalarial therapy can also be con-
sidered. Additionally, in a malaria-endemic area, when a patient
For a given region, bacterial sepsis is most often due to a lim- is initially unresponsive to antibiotic therapy, add antimalarials.
ited number of common pathogens to include streptococci • Minimum: Atovaquone/progauanil (Malarone) 4 × 3 re-
(including S. pneumoniae, which causes pneumonia and men- gimen—4 tablets PO once a day for 3 days
ingitis), staphylococci, Neisseria meningitidis (also a cause of • Best: Artemether/lumafantrine (Coartem) 4 tablets PO
meningitis, particularly common in regions of sub-Saharan Af- initially, then 4 tablets after 8 hours, then 4 tablets PO
rica), and gram-negative bacteria arising in the gut. Treatment twice daily for 2 more days (24 tablets total)
of many of these infections is complicated by rising rates of • Severe Malaria: The optimal treatment for severe ma-
antibiotic resistance worldwide. 12 laria (defined as malaria with associated findings such as
altered mental status, acidosis with lactate >5 mmol/L,
Malaria must be considered high on a differential diagnosis list prostration, hypoglycemia, parasitemia >10%, hemo-
as a leading cause of any febrile illness in an endemic region. globin <7g/dL, creatinine >3mg/dL, pulmonary edema,
In the typical patient from an industrialized country without shock, or pathologic bleeding), the drug of choice is IV

Sepsis Management in Prolonged Field Care | 29