What is the initial approach to a patient with sepsis (systemic inflammatory response syndrome) and a rash?

Initial Approach to Sepsis with Rash

In patients with sepsis and a rapidly evolving rash, antibiotics should be given immediately after blood cultures have been taken, followed by immediate fluid resuscitation with an initial bolus of 500 ml of crystalloid, and lumbar puncture should not be performed at this time. 1

Initial Assessment and Stabilization

• Stabilization of the patient's airway, breathing, and circulation should be an immediate priority 1
• A decision regarding the need for senior review and/or intensive care admission should be made within the first hour 1
• Document the patient's conscious level using the Glasgow Coma Scale 1
• Blood cultures should be taken as soon as possible and within 1 hour of arrival at hospital 1

Management Algorithm for Sepsis with Rash

For patients with predominantly sepsis or a rapidly evolving rash:

• Obtain blood cultures immediately 1
• Administer effective intravenous antimicrobials within the first hour of recognition 1, 2
• Begin fluid resuscitation immediately with an initial bolus of 500 ml of crystalloid 1
• Follow the Surviving Sepsis Campaign guidelines for ongoing management 1
• Do NOT perform lumbar puncture at this time 1

Antimicrobial Selection

• Initial empiric therapy should include one or more drugs with activity against all likely pathogens (bacterial and/or fungal or viral) 1, 2
• For suspected meningococcal sepsis (common cause of sepsis with rash):
  • Use broad-spectrum beta-lactam antibiotics 2
  • For septic shock, consider combination therapy using at least two antibiotics from different classes 3
• For infections associated with respiratory failure and septic shock, consider a combination of a broad-spectrum beta-lactam and an aminoglycoside or fluoroquinolone when Pseudomonas aeruginosa is suspected 3

Therapeutic Endpoints in Septic Shock Resuscitation

• Capillary refill time less than 2 seconds 1
• Mean blood pressure > 65 mmHg 1
• Normal pulses with no differential between peripheral and central pulses 1
• Warm extremities 1
• Urine output > 0.5 ml/kg/hour (urinary catheter required) 1
• Normal mental status 1
• Central venous pressure 8-12 mmHg 1
• Lactate < 2 mmol/L 1

Optimization and De-escalation

• Reassess antimicrobial regimen daily for potential de-escalation 1, 2
• Empiric combination therapy should not be administered for more than 3-5 days 3, 2
• De-escalate to the most appropriate single therapy once susceptibility profile is known 3, 2
• Typical duration of therapy is 7-10 days; longer courses may be necessary for patients with slow clinical response, undrainable infection sites, bacteremia due to Staphylococcus aureus, and certain fungal and viral infections 1, 3

Common Pitfalls to Avoid

• Delaying antimicrobial administration beyond one hour - this can increase mortality by 8% for each hour delay 2, 4
• Performing lumbar puncture in patients with sepsis and rapidly evolving rash before stabilization 1
• Failing to obtain appropriate cultures before starting antibiotics 1, 2
• Using inadequate fluid resuscitation strategies 1
• Continuing broad-spectrum antibiotics unnecessarily when a pathogen is identified 3, 2

Special Considerations for Meningococcal Disease

• Meningococcal disease is a common cause of sepsis with rash and requires immediate treatment 1
• The rash may be petechial or purpuric and rapidly evolving 1
• Even if treatment has been initiated, a lumbar puncture should still be performed as soon as possible after the patient is stabilized, preferably within 4 hours of commencing antibiotics 1
• All clinicians managing such patients should have postgraduate training on the initial management of acute bacterial meningitis and meningococcal sepsis 1