In-depth analysis of the 2021 SSC guidelines, focusing on anti-infective treatment of sepsis

*It is only for medical professionals to read and interpret the 2021 SSC Guidelines for anti-infective treatment of sepsis
.

Sepsis and septic shock affect millions of people around the world every year and are a major medical problem.
Early identification and appropriate treatment are essential to improve the prognosis of the disease
.

This year, the "2021 Sepsis and Septic Shock International Guidelines" (2021 SSC Guidelines) [1] was released in October, providing the latest guidance on the management of sepsis and septic shock, especially anti-infective treatment
.

"2021 Sepsis and Septic Shock International Guidelines"[1] What are the updates on the anti-infective aspects of sepsis? What should be paid attention to when starting antibacterial treatment of sepsis and choosing antibacterial drugs? How to diagnose and treat based on this in clinical practice? In this issue, we invited Professor Cui Na from the Department of Critical Care Medicine of Peking Union Medical College Hospital to answer the hot topics that everyone is very concerned about
.

Question 01 What is sepsis and septic shock? There are two key points in Sepsis 3.
0.
Professor Tina mentioned that as early as 2016, the concept of Sepsis 3.
0 was proposed [2].
Sepsis refers to the imbalance of host response caused by infection, which leads to life-threatening organ damage.
The syndrome is a clinical syndrome with a high fatality rate
.

How to determine the occurrence of infection and how to determine the occurrence of organ damage is the two key points.
In the current clinical practice, the use of antibiotics by doctors considering the patient's infection and an increase in SOFA score of ≥2 points are used as the diagnostic criteria
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The prerequisite for the diagnosis of septic shock is compliance with sepsis.
Septic shock, also known as septic shock, refers to a clinical syndrome that causes circulatory failure due to infection, which causes tissue and organ perfusion insufficiency
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Question 02 What is your opinion on the newly released "2021 International Guidelines on Sepsis and Septic Shock"? The 2021 SSC guide is worth studying and the 2021 SSC guide is of great significance
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Professor Cui Na pointed out that the 2021 SSC Guidelines do not directly guide clinicians to treat diseases, but provide a diagnosis and treatment idea or idea for doctors to refer to or learn from.
Think about the actual clinical situation
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Question 03 In the "2021 Sepsis and Septic Shock International Guidelines", what are the recommendations for the start time of antimicrobial therapy for sepsis? Assessing adult patients with suspected sepsis and without shock within 3 hours Regarding the initiation time of antimicrobial therapy for sepsis, Professor Cui Na explained that the 2021 SSC guidelines point out that the initiation time of antimicrobial drugs should be differentiated according to the characteristics of the patient [1]: for possible occurrence Adult patients with sepsis or septic shock, the recommendations of the guidelines have not changed, antibacterial drugs should be used as soon as possible, and culture specimens should be collected before use
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Unlike the previous ones, the guidelines suggest that for adult patients with suspected sepsis and without shock, it is recommended that the possibility of rapid assessment of infectious and non-infectious causes of acute disease should be completed within 3 hours after consultation
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If concerns about infection persist, antibiotics should be used within 3 hours after sepsis is first considered
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The 2021 SSC guidelines emphasize that not every patient suspected of sepsis or septic shock should take antibiotics within one hour, but for some patients, it should take a certain amount of time to screen for the infection and identify the source of infection.
Lead to the abuse of antibiotics and increase drug resistance
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Question 04 In the "2021 Sepsis and Septic Shock International Guidelines", what are the recommendations for the selection of antibiotics for patients with sepsis? Under what circumstances is it appropriate to use carbapenem antibacterial empirical treatment? Anti-infection treatment experience sharing Professor Cui Na also shared her anti-infection experience in combination with her clinical practice, and put forward many aspects that need attention
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▌The choice of antibacterial drugs should be combined with local circulation data.
Professor Cui Na emphasized that the choice of antibiotics must be based on the local epidemiological survey data
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For example, in the United States, methicillin-resistant Staphylococcus aureus (MRSA) is more common in severe infections, but it accounts for a relatively low proportion in China's ICU
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For example, in Peking Union Medical College Hospital, the proportion of bacterial species in clinically isolated specimens suggests that MRSA is less common than some Gram-negative bacilli and does not require empirical medication for MRSA
.

Pan-drug-resistant Gram-negative bacteria infection is an important clinical challenge, but the increase in drug resistance rate is a relative concept.
For example, from 2011 to 2018, the drug resistance rate of Klebsiella pneumonia in Peking Union Medical College Hospital was 13% About 13% is a relatively high data, but we must also realize that it is only 13%, and most of them are sensitive to other antibiotics.
In this case, we must use antibiotics reasonably and correctly, and we should not be afraid of pandemics.
Infections with resistant bacteria cannot be treated blindly and empirically
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▌Carbapenem drugs are still a better choice for anti-infection.
Carbapenem drugs have been the "ace choice" in the past few decades, and they have a good effect on patients who are very critical and whose infection is difficult to control.
Although carbapenem-resistant bacteria have appeared, a large number of patients need to use this type of drug, and its anti-infective effect is still very good, such as people with complex abdominal infections
.

But be vigilant and not abuse carbapenem drugs
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Question 05 In the "2021 Sepsis and Septic Shock International Guidelines", what other important contents are worth paying attention to for the antibacterial treatment of sepsis? Antibacterial treatment has other important contents worthy of attention.
The anti-infective strategy of critically ill patients should be decided and controlled by critically ill doctors because there are many factors that affect the effectiveness of anti-infective treatment in critically ill patients, such as more fluid intake and volume of distribution of antibiotics.
There will be very big changes.
Complications such as liver failure and renal failure require continuous renal replacement therapy (CRRT) or extracorporeal membrane oxygenation (ECMO).
Intensive care doctors know the most about critically ill patients, so they are resistant to infection The strategy must be controlled by the critically ill doctor
.

It is necessary to have a clear understanding of the effects of pharmacokinetics (PK)/pharmacodynamics (PD) on anti-infective treatments, so as to better apply antibiotics and optimize antimicrobial drug delivery strategies
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▌While fighting infection, control the source of infection.
While using antibiotics, you must look for the infection and remove the infection as soon as possible.
This may be more important than the use of antibiotics
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For example, patients with pulmonary infection have poor airway drainage, and the significance of only applying antibiotics to control the infection is very small
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The removal of infection foci in some severely infected patients still requires multidisciplinary diagnosis and treatment (MDT)
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▌It is recommended to refer to PCT when stopping antibacterial drugs.
For procalcitonin (PCT), the guidelines clearly point out that PCT should not be used when antibiotics are used, and it is recommended to refer to PCT when degrading or stopping antibiotics.
This is also a point of this year's guideline update
.

If the PCT is low, you can consider discontinuing antibacterial drugs.
The negative expected value of PCT is very effective
.

It should be noted that there are many influencing factors of PCT, and the reasons for the increase in PCT must be carefully analyzed.
The PCT of infected patients may increase, but the elevated PCT does not mean that the patient must have infection
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  Summary Sepsis is a topic that requires extensive attention
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How to understand sepsis, a deeper understanding of the pathophysiological mechanism of the occurrence and development of sepsis, and its possible clinical consequences are of vital importance to ICU doctors
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Timely and correct anti-infective treatment is a key link in the management of sepsis.
I hope that today’s discussion can be helpful to all doctors in their future work
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References: [1] Evans L, Rhodes A, Alhazzani W, et al.
Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021[J].
Intensive care medicine, 2021, 47(111181-1247.
[2 ] Rhodes A, Evans LE, Alhazzani W, et al.
Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016[J].
Intensive care medicine, 2017, 43(3): 304-377.
Expert profile Cui Dr.
Na, Chief Physician of the Department of Critical Care Medicine of Peking Union Medical College Hospital, and supervisor of postgraduates for postgraduates
.

Standing committee member of the Critical Care Professional Committee of the Chinese Women Physicians Association, expert on the senior talent evaluation project of the National Health Commission, expert on the degree evaluation of the Ministry of Education, and expert on the evaluation of the National Natural Science Foundation of China
.

Research direction: severe infection, sepsis immunity, severe hemodynamics
.

Presided over 2 National Natural Science Foundation of China, 1 Beijing Natural Science Foundation, 1 Tibet Natural Science Foundation project, presided over the major project of Beijing Municipal Science and Technology Commission, and the transformation of the Chinese Academy of Sciences Medicine, Chinese Medical Association and other industry fund a number of national, provincial issues
.

the first author and corresponding author in domestic and foreign professional journals published a number of works, including SCI works more than 30 (total IF> 90), the master / Participated in the compilation of more than 10 academic monographs and teaching materials
.

Served as peer review reviewer for Journal of Hospital Infection, BMC Psychiatry, European Journal of Inflammation, Chinese Medical Journal and other journals
.

This article is only used to provide scientific information to medical and health professionals, and does not represent the platform’s position.
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