Severe Sepsis and Septic Shock Antibiotic Guide Surviving Sepsis: The choice of empirical antimicrobial therapy depends on complex issues related to the patient s history, including drug intolerances, underlying disease, the clinical syndrome, and susceptibility patterns of pathogens in the community, in the hospital, and that previously have been documented to colonize or infect the patient. Infectious disease consultation may be of assistance in the selection of empirical therapy, but only if it does not delay the initiation of appropriate therapy. Table 1: Antibiotic selection options for healthcare associated and/or immunocompromised patients Table 2: Antibiotic selection options for community acquired, immunocompetent patients Table 3: Antibiotic selection options for patients with simple sepsis, community acquired, immunocompetent patients requiring hospitalization. Table 1: Antibiotic selection options for healthcare associated and/or immunocompromised patients Severe Sepsis or Septic Shock (Health Care Associated 1 Immunocompromised 2 ) Antibacterial A Antibacterial B Antibacterial C Antifungal Undifferentiated or Vascular Access Device Infection 3 4 q12h - if at risk of VRE 5 Tobramycin 6 7mg/kg - if at risk of P. aeruginosa 7 Caspofungin 70mg IV ONCE + caspofungin 50 mg - if at risk of invasive candidiasis 8 Pneumonia Aztreonam 2g IV q8h Azithromycin 500mg Levofloxacin 750mg PLUS Tobramycin 7mg/kg - if at high risk of P. aeruginosa 7 1 Healthcare associated: intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days, residence in a nursing home or other long-term care facility, hospitalization in an acute care hospital for two or more days within the prior 90 days, attendance at a hospital or hemodialysis clinic within the prior 30 days; Immunocompromised: Receiving chemotherapy, known systemic cancer not in remission, ANC <500, severe cell-mediated immune deficiency 3 Beta-lactam antibiotics should be administered over 3 4 hours. 4 Give loading dose of 25 30 mg/kg. May order per pharmacy 5 VRE risks may include liver transplant, known colonization, prolonged broad antibacterial therapy, prolonged profound immunosuppression 6 Single dose of 7 mg/kg 7 P. aeruginosa (and other resistant GNR) risks may include hospitalization within 90 days, antibiotics within 30 days, severe pneumonia, significant immunosuppression, poor functional status, bronchiectasis 8 Invasive candidiasis risks may include intra-abdominal surgery with perforated viscus, central venous catheter in place for >5 days, pancreatitis, Candida colonization at >2 sites
Urinary Tract Infection Aztreonam 2g IV q8h q12h q12h - if at risk of VRE 5 tobramycin Intra-Abdominal Infection aztreonam q12h - if at risk of VRE 5 Caspofungin 70mg IV ONCE + caspofungin 50 mg - if at risk of invasive candidiasis Skin/Skin Structure Infection - Pure cellulitis with MRSA Risk 9 Skin/Skin Structure Infection Cellulitis with Special Risks 9 + Metronidazole 500mg IV Q8H Dose (existing EPIC entry) + vancomycin Cefazolin 2g IV Q8H Nafcillin 2g IV Q4H 9 Malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites, diabetic foot ulcer
Necrotizing Fasciitis (including Fournier s Gangrene), Clostridial Gas Gangrene or Myconecrosis + Metronidazole 500mg IV Q8H Q12H ± Clindamycin 600mg IV Q8H Bacterial Meningitis Spontaneous Bacterial Meningitis Post- Trauma or Neurosurgery + Metronidazole 500mg IV Q8H Ceftriaxone 2g IV Q12H infused over 3 hours Ampicillin 2g IV Q4H (>50 year of age immunocompromise d) Surviving Sepsis: The antimicrobial regimen should be reassessed daily for potential de-escalation to prevent the development of resistance, to reduce toxicity, and to reduce costs. When used empirically in patients with severe sepsis, we suggest that combination therapy should not be administered for >3 5 days. De-escalation to the most appropriate single therapy (or combination therapy if indicated) should be performed as soon as the susceptibility profile is known. Infectious Disease consultation should be considered in many cases. Beta-lactam allergy: If there is a history of type I immediate hypersensitivity (e.g., urticaria, angioedema, anaphylaxis, bronchospasm), substitute aztreonam for piperacillin/tazobactam, meropenem, or cefepime (unless the reaction was to ceftazidime). For a history of other serious reactions (Type II, III, or IV e.g., hemolytic anemia, thrombocytopenia, serum sickness, erythema multiforme, SJS/TEN, DRESS, etc), avoid the specifically implicated drug, but others in the class may be used, except for cephalosporins with same R group side chains. If a beta-lactam agent is preferred, may consider consulting Allergy & Immunology for consideration of graded challenge, de-sensitization, or to rule out possible drug allergies when the patient is clinically stable. Fluoroquinolone allergy: If there is a history of an immediate reaction to one fluoroquinolone, avoid use of any of the class. Vancomycin allergy: Avoid if there is a history of bullous reaction, or of associated thrombocytopenia. If there is a history of possible immediate reaction or macular skin reactions, carefully assess the history. If the reaction involved flushing, pruritus, or urticaria, then, premedicate with an antihistamine (diphenhydramine or hydroxyzine) and acetaminophen, hold/reduce opiates (if possible), and infuse at ½ or 1/3 rate over 2-3 hours.
Table 2: Antibiotic selection options for community acquired, immunocompetent patients Severe Sepsis or Septic Shock (Community Acquired AND Immunocompetent) Undifferentiated Antibacterial A Ertapenem 1g IV q24h Antibacterial B Dose + vancomycin 10 Antibacterial C 4.5g IV Q8H infused Aztreonam 2g iv q8h Pneumonia Ceftriaxone 2g IV q24h + Azithromycin 500mg IV q24h Urinary Tract Infection Intra-Abdominal Infection Levofloxacin 750mg IV q24h Ertapenem 1g IV q24h Aztreonam 2g iv q8h 4.5g IV Q8H infused Ertapenem 1g IV q24h Dose + vancomycin (Especially if GPC on Gram stain of urine) Dose + vancomycin Vancomycin Loading Dose (existing EPIC entry) + vancomycin Skin/Skin Structure Infection - Pure cellulitis with MRSA Risk 9 Skin/Skin Structure Infection Cellulitis with Special Risks 11 Aztreonam 2g iv q8h Cefazolin 2g IV q8h Nafcillin 2g IV Q4H 4.5g IV Q8H infused infused over 3 hours Dose + vancomycin Dose + vancomycin 10 Give loading dose of 25 30 mg/kg. May order per pharmacy 11 Immersion injuries, and animal bites
Bacterial Meningitis Spontaneous + Metronidazole 500mg IV Q8H Aztreonam 2g iv q8h + metronidazole Ceftriaxone 2g IV q12h Dose + vancomycin Ampicillin 2g IV q4h (>50 years of age) # Vancomycin is an option but we need to determine if going to have equal standing on the list taking into account cost and resistance. ^ Ceftaroline and Levofloxacin is an option but Medicare reimbursement needs to be evaluated. $ Fournier s Gangrene suspected use healthcare associated skin/soft tissue recommendations
Table 3: Antibiotic selection options for patients with simple sepsis, community acquired, immunocompetent patients requiring hospitalization. Simple Sepsis, Community Acquired Undifferentiated Antibiotic A Ceftriaxone 2g IV q24h Antibiotic B Antibiotic C Levofloxacin 750mg iv q24h PNA^ Ceftriaxone 1g + Azithromycin 500mg IV q24h/doxycycline 100mg IV q12h GU Levofloxacin 750mg iv q24h Ceftriaxone 1g ABD Ciprofloxacin 400mg iv q12h Ceftriaxone Ciprofloxacin Metronidazole 500mg iv q8h Skin/Skin Structure Infection - Pure cellulitis with MRSA Risk 9 Skin/Skin Structure Infection 3.375g Cellulitis with Special Risks 12 IV Q8H infused Dose + vancomycin (lumps/bumps/pus, prior MRSA NARES) Dose + vancomycin Bacterial Meningitis Spontaneous infused over 3 hours Cefepime 1g IV Q6H + Metronidazole 500mg IV Q8H Ceftriaxone 2g IV q12h Dose + vancomycin Ampicillin 2g IV q4h (>50 years of age) # Vancomycin is an option but we need to determine if going to have equal standing on the list taking into account cost and resistance. 12 Immersion injuries, and animal bites