Sepsis case Dr Suzy FitzGerald

Day 1 65 year-old man Presented to ED at 03.00 Sudden onset pain in left hip at 23.30 Became much worse in subsequent 30 minutes Unable to weight bear Sweats and shivers since 00.00

Day 1 Past history Osteoarthritis Metal on metal resurfacing left hip May 2003 Articular surface replacement right hip November 2003 Right THR 2008 Left TKR 2012 Hiatus hernia Hyperlipidaemia

Day 1 Examination Temp 38.0°C BP 142/82 HR 110 RR 18 O2 sats 98% (on room air) EWS 1 ‘irritable’ left hip Pain on passive movement of left hip Tenderness left groin No cellulitis

What would you do next?

What would you do next? Routine bloods Blood cultures Imaging CXR X-ray left hip

Day 1 Blood cultures taken WCC 16.1 Hb 15.9 Plts 280 U&E normal CRP 4.0 (0-5.0) Urinanalysis - normal

What is wrong with the patient?

What is wrong with the patient? Sepsis = SIRS and infection (suspected or confirmed) This patient has SIRS and suspected infection WCC > 12 (16) HR > 90 (110) Likely source is left hip Infected prosthesis Soft tissue infection

What do you do next?

What do you do next? Orthopaedic review Imaging – CT pelvis ? antibiotics

Day 1 06.30 – orthopaedic registrar review Likely deep infection left hip - ? abscess IV fluids nil by mouth hold antibiotics CT scan

Day 1 - 15.30 – CT pelvis and left hip

CT report Large 12 x 10 x 3.5 cm fluid collection related to the left hip joint and prosthesis, extending along left iliopsoas muscle Although not possible to exclude septic arthritis given the history provided, this appearance can be encountered in the setting of metal on metal hip prostheses without superimposed infection

Day 1 18.00 – orthopaedic consultant review CT scan reviewed - ? metal wear ? infection For ultrasound-guided aspiration Blood cultures if temperature > 38°C Not to start antibiotics until discussed with orthopaedic team 18.30 – ultrasound-guided aspiration 30ml dark viscous fluid aspirated No residual fluid

Day 1 23.30 transferred to orthopaedic ward Temp 38.0°C BP 120/70 HR 98 RR 18 O2 sats 95% (on room air) EWS 0

Would you give antibiotics now?

Day 2 02.00 Temp 38.2°C No other obs recorded Blood cultures taken 11.00 Temp 36.6°C WCC 22.2 CRP 399 Blood cultures from day 1 – sterile to date Gram stain of left hip aspirate - ++ pus ++ GPC in clusters

What do you advise?

Day 2 11.30 Orthopaedic registrar informed by microbiology registrar, advised start vancomycin 12.00 Vancomycin 1g 12-hourly prescribed First dose given Weight 91kg, eGFR 87mL/min; if hospital policy followed, should have had 2g loading dose, then 1.5g 12-hourly with trough before 5th or 6th dose. Had 4 doses in total. Trough not checked.

Day 3 12.00 Left hip aspirate (from day 1) – Staph. aureus Blood cultures (from day 2) – GPC in clusters on Gram stain of aerobic bottle Temp 38.5°C WCC 20.4, CRP 466 SIOC informed, advised to continue vancomycin

Day 3 23.45 Temp 40.5°C with rigors BP 98/52 HR 136 RR 22 O2 sats 87% on room air EWS 10 WCC 17.9, CRP 423

Day 3-4 Temperature Heart rate RR and oxygen sats Blood pressure

What do you do now?

What do you do now? Urgent review by senior NCHD Sepsis 6 within 1 hour Cultures Lactate Urine monitoring Oxygen Fluid challenge Antibiotic therapy

Day 4 00.00 – orthopaedic registrar review Unwell, rigors Discussed with orthopaedic consultant on call Sepsis 6? Flucloxacillin 2g IV 6-hourly added IV fluids – 1L over one hour Oxygen

What else should be done?

What else should be done? Source control

Day 4 00.45 – theatre BP 117/65 Frank pus ++ Thorough soft tissue and capsular debridement 6L washout Pus, tissue sent for C&S

Day 4 04.15 – back from theatre Temp 38.1°C BP 127/81 HR 118 RR 18 O2 sats 96% on 60% O2 EWS 6

Day 4 11.00 – microbiology review on ward Aspirate left hip – MSSA (resistant penicillin, fusidic acid) Blood cultures day 2 – MSSA Temp 38.3°C BP 126/69, HR 112, RR 16, O2 sats 96% on 60% O2 EWS 6 WCC 17.9, CRP 388 Vancomycin stopped Flucloxacillin increased to 2g IV 4-hourly

Day 5 09.30 – microbiology review on ward Temp 39.5°C BP 105/62, HR 84, RR 18, O2 sats 94% on 4L O2 EWS 6 WCC 11.8, CRP 390 Pus and tissue left hip day 3 - Staph. aureus

What next?

Day 5 11.00 – theatre Washout left hip – looked clean Swabs x 5 - MSSA

Days 6-7 Remained febrile Normotensive, HR 80-90 Intermittent supplemental oxygen (2L) EWS 0-4 Pain ++ in hip

What are you thinking?

What are you thinking? Ongoing infection – need for further source control? Possibility of additional focus of infection? Imaging CT/MRI Bone scan Echo Blood cultures

Day 7 Blood cultures taken MRI lumbar spine and pelvis ? discitis ? psoas abscess

Day 7 – MRI lumbar spine and pelvis No evidence of discitis or epidural abscess Left iliacus muscle abscess (5 x 2 x 6 cm)

Day 8 – bone scan Increased uptake in upper left tibia Indicates active inflammation Suspicious for infection at left prosthetic knee joint Team felt changes likely post-surgical

Day 9 Temp 38.3°C WCC 22.8, CRP 120 Returned to theatre Left hip macroscopically clean, washed out Drainage left iliacus abscess – pus evacuated from iliac fossa, debridement Tissue x 1 – MSSA Swab x 1 – MSSA

Day 11 Temp 38.3°C WCC 20.2, CRP 190 Transthoracic echo Normal valves No vegetations seen

Day 12 Temp 36.2°C WCC 18.9, CRP 144 1st stage revision Vancomycin spacer Plan 6 weeks antibiotics 2 weeks break 2nd stage

Further progress Remained afebrile Discharged on day 26 on OPAT (cefazolin) WCC 7.3, CRP 7 Successful second stage Dislocation of THR on 2 occasions

Key points Recognition EWS Resuscitation Sepsis 6 Source control Identify Control – may need repeated interventions Consider additional sources

CONTROL