Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Describe how to assess whether a patient with sepsis is responding to fluid management
2. Discuss the considerations when beginning antimicrobial therapy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Feb 21 2019 through Feb 21 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

Sepsis remains a significant and potentially preventable cause of maternal morbidity and mortality. SMFM highlights the importance of implementing an ‘early warning system’ to avoid delay and recommends that

…sepsis and septic shock be considered medical emergencies and that treatment and resuscitation begin immediately (GRADE 1B)

We recommend that providers consider the diagnosis of sepsis in pregnant patients with otherwise unexplained end-organ damage in the presence of an infectious process, regardless of the presence of fever

Clinical Actions

• Order
  • Cultures: Blood | Sputum | Urine and other samples as indicated
    • CMQCC recommends cultures be drawn upon diagnosis even if antibiotic therapy has already been initiated
  • Serum lactate levels
• Begin
  • Antibiotics within 1 hour (see ‘Key Points’ below)
  • Broad Spectrum (anaerobic and aerobic gram-positive and gram negative bacteria)
• Determine source as early as possible following initiation of resuscitation and initiation of antibiotics
  • Imaging as necessary
  • Manage depending on findings (e.g. abscess drainage as required)
  • Use the least invasive approach possible (e.g. percutaneous best when appropriate) except in case where more invasive approach is desirable (e.g., debridement if indicated)

Fluids

• SMFM cautions that aggressive fluid resuscitation in pregnant women may result in ‘third spacing’ and recommends initial administration of 1-2 liters of crystalloids (Grade 1C)
• CMQCC states

We recommend that resuscitation from sepsis-induced hypoperfusion include at least 30 mL/kg of intravenous crystalloid fluid within three hours of recognition of sepsis

Surviving Sepsis Campaign does not recommend one crystalloid over another

• Do not use CVP or pulmonary artery occlusion pressure to guide fluid resuscitation
• Determine if patient is fluid responsive
  • Pulse pressure variation using arterial line wave form
    • Reliable with [1] sedation [2] positive pressure controlled mechanical ventilation and [3] in sinus rhythm
    • Pulse pressure should vary ≥13% with the respiratory cycle
  • Passive leg raise to 30-45 degrees (spontaneous breathing or not in sinus)
    • Auto transfusion results in increased cardiac output
    • May not be a good test in third trimester: Use 250 – 500cc cardiac bolus rather than leg raise

Vasopressors and Inotropes

• Use vasopressors in hypotensive patients if
  • Not fluid responsive or
  • Further fluid therapy is contraindicated (e.g. pulmonary edema)
• First line: Norepinephrine
  • Target MAP: >65 mmHg
  • SMFM recommends individualizing in pregnant patients taking in to account clinical context and overall perfusion
  • Norepinephrine appears to be safe in pregnancy although high-quality data is limited
• Other vassopressors
  • Data on other vasopressors more limited
• Consider dobutamine (inotrope) to increase cardiac output if
  • • Patient remains hypotensive following fluids and vasopressors
    • Myocardial dysfunction is present
• Start hydrocortisone 200 mg/day (continuous infusion) if no response to norepinephrine

Note: Initiate DVT prophylaxis

KEY POINTS:

Antibiotic Therapy

• Consider the following when beginning antimicrobial therapy
  • Initially, choice of antibiotic will likely be empiric
  • Choice of antibiotic will be dependent on
    • Source | Local resistance | Hospital protocols
  • Start with broad spectrum coverage, including anaerobic and aerobic gram-positive and gram-negative bacteria
  • Consultation with infectious disease may be appropriate

CMQCC Antibiotic Recommendations if Source Unknown (at least
one antibiotic for Gram-negative and anaerobic coverage PLUS one for Gram-positive coverage)

7 to 10 day duration usually adequate

• Gram-negative plus anaerobic coverage
  • Piperacillin/tazobactam 3.375 g IV q8h (extended infusion) or 4.5 g IV q6h or
  • Meropenem 1 g IV q8h (if recent hospitalization or concern for multi-drug resistant organisms) or
  • Cefepime 1-2g IV q8h plus metronidazole 500 mg IV q8h or
  • Aztreonam 2 g IV q8h (for women with severe penicillin allergy) plus metronidazole 500 mg IV q8h or
  • Aztreonam 2g IV q8h plus clindamycin 900 mg IV q8h

PLUS

• Gram-positive coverage
  • Vancomycin 15-20 mg/kg q8h-q12h (goal trough 15-20 mcg/mL) or
  • Linezolid 600 mg IV/PO q12h (for women with severe vancomycin allergy)

SMFM Guidance Provides Antibiotic Recommendations Dependent on Source

• Community-acquired pneumonia
  • Cefotaxime | Ceftriaxone | Ertapenem | Ampicillin plus azithromycin | Clarithromycin | Erythromycin
• Hospital-acquired pneumonia: Low risk
  • Piperacillin-tazobactam | Meropenem | Imipenem | Cefepime
• Hospital-acquired pneumonia: High risk or mortality
  • Double coverage for Pseudomonas
    • Beta lactam plus an aminoglycoside or quinolone
    • MRSA coverage: Vancomycin or linezolid
  • Chorioamnionitis
    • Ampicillin plus gentamicin
    • Cesarean: Add clindamycin or metronidazole for anerobic coverage
  • Endomyometritis
    • Ampicillin, gentamicin, and metronidazole (or clindamycin) or
    • Cefotaxime or
    • Ceftriaxone plus metronidazole
  • UTI
    • Gentamicin plus ampicillin or
    • Carbapenem or
    • Piperacillin-tazobactam
  • Abdominal infections: Uncomplicated
    • Ceftriaxone | Cefotaxime | Ceftazidime | cefepime plus metronidazole
  • Abdominal infections: Complicated
    • Carbapenem | Piperacillin-tazobactam
  • Skin and soft tissues (necrotizing)
    • Vancomycin plus piperacillin-tazobactam
    • If Streptococcus Group A or Clostridium perfringens are present: Penicillin G plus clindamycin

Fetal Assessment and Delivery

• Fetal assessment: Consider the following
  • Electronic fetal monitoring ≥24 weeks
  • Corticosteroids for fetal lung maturity >23 to 24 weeks of pregnancy
• Delivery (Grade 1B recommendations)
  • SMFM recommends against delivery for sepsis if this is the sole indication
  • Delivery should be dictated based on obstetric indications

Learn More – Primary Sources:

SMFM Consult Series: Sepsis during pregnancy and the puerperium

The Surviving Sepsis Campaign Bundle 2018 Update

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016

CMQCC Toolkit: Improving Diagnosis and Treatment of Maternal Sepsis

Related ObG Topics:

SMFM & CMQCC Guidelines: Making the Diagnosis of Sepsis in Pregnancy

Chorioamnionitis: ACOG Committee Opinion on Diagnosis and Management

What is the Best Practices Prevention Bundle for Post Cesarean Infection?