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Recognising sepsis in primary care
James Larcombe
Sedgefield
Co Durham
Recognising sepsis in primary care
• Background and Context
• Sepsis Trust and Primary Care
• Investigations
• Children and fever
• Prevention
• Future audit, guidance
• Vignettes
Context of primary care 1
• Age-variable presentation
• First to decipher narrative of illness
• Multimorbidity, psychosocial, and holistic care
• Diversity of care settings
• Access to technology
Context of Primary Care 2
• High prevalence self-limiting illness
• Low prevalence of serious illness
• Non-specific presentations
• Sequential development of symptoms/signs
• Potential for rapid deterioration
Incidence all infections
ICU
IP
A&E
OOH
1ry Care
Community
Prevalence serious infections
ICU
IP
A&E
OOH
1ry Care
Community
Presence of amber/red flags
ICU
IP
A&E
OOH
1ry Care
Community
Antibiotic stewardship
• Resistance related to prescribing rates
• Dip in late 1990s (SMAC); rise in 2000s
• Median - Abs 54% adult (18-59) RTI consults1
• Amoxicillin no benefit for non-pneumonia LRTI2
• Broad spectrum Abs and C diff
• Drug allergy, side-effects and spurious allergy
• 53% patients attending with LRTI expect Abs3
• Guideline knowledge increases Ab Pxing4
1) Gulliford, BMJ Open, 2014; 2) GRACE; 3) McNulty, BJGP, 2013; 4) Linder ,Int J QHC, 2010
GP screening for sepsis
More than a self-limiting infection?
• Temp >38.3 (or <36) oC
• Resps >20
• HR > 90
• Confusion etc
• Glucose > 7.7
• SBP <90
• Resps >25
• HR >130
• O2 sats < 91%
• Purpuric rash
• Poorly responsive
Infection symptoms, acute deterioration, unexplained illness (esp. if high risk)
Sepsis Six in primary care
• High flow O2
• Consider infective source/ blood cultures
• Empirical IV antibiotics
• Lactate and FBC
• IV fluids
• Urine output measurement
Lactate?
• Point-of-care machines
• Significant lactate values for 1ry Care decision-making?
• Different purpose – spectrum bias possible
• Machine cost
• Infrequent use - upkeep / sticks out-of-date?
Spectrum bias in sore throat
Study Site Ages Pop % strep
LR+ Post-test
Centor 1981 ED All 17 2.3 32%
Dagnelie 1998 GP All 33 1.8 47%
McIsaac 2004 GP 3-17 34 4.1 68%
Willis BH, Family Practice, 2008
CRP?
• Performance alone insufficient to rule in/ out serious illness in children1 and adults2
• Doesn’t help CURB-65 to predict mortality3
• Reduces antibiotics for respiratory infections4
• Cost-effective5
• CRP (+ O2 sats) an additional marker in GP6?
1) Freyne, Clin.Ped 2013; Limper J.Inf 2010; NICE UTIC- CG 54; 2) Engel, Fam Pract 2012; 3) Yamamoto, BMJ Open, 2015 ; 4) Huang, BJGP, 2013; 5) Hunter, Adv ther, 2015; 6) ERNIE2
Childhood infections
• 45% child admissions due to infection
• <1/4 in previously healthy children
• 20% childhood deaths infective esp. under-5s
• 1150 infection related admissions/100,000/yr
• Serious acquired invasive infection
– child < 15: 6/100,000/yr
– Child < 1 : 38/100,000/yr
Performance of NICE traffic light
Prevalence infection
Typical setting
Sensitivity Specificity LR+
Low GP 100% 1.0% 1.01
Intermediate ED 97.3% 26.7% 1.33
High Inpatient 87.1% 28.7% 1.22 Based on Verbakel, BMC Med, 2013
Amber/Red
Sensitivity Specificity LR+
Amber 100% 0.12% 1.00
Red 62% 74.5% 2.43 Based on Verbakel, Paed Emerg Care, 2014
Self-diagnosis and clinical acumen?
Symptom/ sign LR+
Cyanosis 2.7 – 52
Rapid breathing 1.3 – 9.8
Shortness of breath 1.1 - 9.3
Poor peripheral circulation 2.4 - 39
Petechial rash 6.2 - 84
LR+
Parental concern 14.4
Clinician instinct 23.5
Van den Bruel Lancet 2010 (Systematic review) / DARE
Vaccination
• Childhood regime
• HiB and S pneum < 1% childhood infections
• Pneumococcal/ flu >65 + high-risk <65
• High incidence pneumonia in elderly
• Multimorbidity – IDDM; COPD highest risk serious infections1
1) Van de Nadort BJGP, 2009
Audit and guidelines
• In GP toolkit:
• ‘Clinical guidelines’ (recommendations) based on GP screening document
• Exemplar standards – audit • Appropriate serious infection
• Appropriate self-limiting illness
• Coding issues
Patient 1: Female aged 63 D1: Own GP triage- unwell 4/7 cough & fever. Usually fit & active D1 pm: T 38.3oC, P 92, BP 120/60, RR 14, sats 97%, chest clear. Diagnosis: viral? Supportive Px D1 2200: Confusion and headache = stroke? 999-> obs as before and recontact 999 if worse - husband rang 999 but none available D2 0030: barely able to get out of bed, ‘like an old woman’, disoriented?, bluey lips? D2 04:30: Visit P 96 BP105/60 T36.6oC (on paracet+ibuprofen), chest clear, abdo NAD. BM (ambulance) 8.7. Urine: + Bld, + Prot, L+N- Px Nitrofurantoin. D3 06:30: Felt worse+ pain in chest D3 0700: T39.1oC; R chest pain not PE like. Adv visit own GP D3 0830: admitted - pneumonia requiring ventilation on ITU.
Patient 2: Male aged 35 D1: Very sore throat. Viral? Supportive management. D7: Bad ear pain, fever, D&V T38oC, bulging R ear drum, chest clear. Viral? Px codeine See own GP if no better. D9 0100: D&V, new confusion. 02:45 (tel consult) as D7 + fever, D&V, dizzy on standing, urine dark. Visit ENP: T 37.5oC, P 115, BP 110/60, sats 96%, RR 16, urine NAD but concentrated, ear disch +++, chest/throat NAD. Diagnosis: ASOM+vomiting. Px: amoxicillin; IM +buccal antiemetic . Review own GP if no better. D10: 999- worse, barely able to get out of bed, ‘like an old man’, more D and V. Obs: P 110, BP 110/60, temp 37.5oC, sats OK. OOH GP called: diarrhoea due to antibiotics. Px: supportive. D11: Own GP- visit P115, BP 105/60, unable to get out of bed. Uncertain diagnosis, but “clearly not right”. Admitted. Eventual diagnosis = mastoiditis with transverse sinus thrombosis.
Recognising sepsis in primary care
• Background and Context
• Sepsis Trust and Primary Care
• Investigations
• Children and fever
• Prevention
• Future audit, guidance
• Vignettes
