Antibiotics - Sepsis

For more clinical management please see SEPSIS page.

Sepsis Source Unclear

Infection	Septicaemia Source unclear
Most likely organisms	Coliforms, S. aureus, Streptococcus sp.
Empiric treatment	Cefriaxone 2g iv q24h plus Gentamicin 5mg/kg q24h iv (max 480mg q24h). If anaerobic cover needed: Add Metronidazole 500mg q8h iv. If risk factors for MDRO: Contact micro. Only if documented history of ESBL: Meropenem 1g tds iv
In penicillin allergy	Ciprofloxacin 400mg q8-12h iv plus Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg q12h iv plus Metronidazole 500mg q8h iv. If severe sepsis or septic shock add Gentamicin 5mg/kg q24h iv (max 480mg q24h). If documented history of ESBL/ MDRO: Check sensitivities. If sensitive & no recent exposure: As above. Otherwise seek advice from microbiology
Duration
Comments	Seek advice for oral options. If MUH / SIVUH Piperacillin-tazobactam 4.5g q8h iv. If severe sepsis or septic shock add Gentamicin 5mg/kg q24h iv (max 500mg q24h). If MRSA: Add Vancomycin Loading Dose the 15mg/kg q12h iv. If MUH / SIVUH Piperacillin-tazobactam 4.5g q8h iv. If severe sepsis or septic shock add ,Gentamicin 5mg/kg q24h iv (max 500mg q24h). If MRSA: Add Vancomycin Loading Dose then 15mg/kg q12h iv.

Sepsis Skin, Soft Tissue, Line Assoc.

Infection	Skin / soft tissue sepsis
Most likely organisms	S. aureus (inc MRSA), S. pyogenes
Empiric treatment	Community acquired, no MRSA history: Flucloxacillin 2g q6h iv. Hospital acquired / history of MRSA: Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg q12h iv Add Clindamycin 900mg-1.2g q6h iv and Benzylpenicillin 2.4g q6h iv if invasive Group A strep. suspected.
In penicillin allergy	Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg q12h iv. Add Clindamycin 900mg-1.2g q6h iv if severe sepsis or septic shock or invasive Group A strep. suspected.
Duration
Comments	If peripheral line sepsis, remove line and replace at a different site. For central line sepsis, perform central and peripheral blood cultures. Remove line if possible. When microbiological results available, tailor antibiotic therapy where appropriate.Vancomycin dosing.

Sepsis Urinary Tract

Infection	Urinary tract sepsis
Most likely organisms	Coliforms, Enterococcus sp.
Empiric treatment	Co-amoxiclav 1.2g q8h iv plus Gentamicin 5mg/kg iv (max 480mg q24h), depending on severity. Seek daily review of Gentamicin. Risk factors for MDRO: Contact micro. Only if documented Hx of ESBL: Meropenem 1g q8h iv.
In penicillin allergy	Ciprofloxacin 400mg q8-12h iv plus Gentamicin 5mg/kg iv (max 480mg q24h). If documented history of ESBL/ MDRO: Check sensitivities. If sensitive & no recent exposure: As above. Otherwise seek advice from micro.
Duration
Comments	Send urine sample in addition to blood culture. Previous culture results may help guide therapy. Seek advice on oral options and duration of therapy Gentamicin is rarely required for more than 7 days.

Sepsis Intra-abdominal

Infection	Intra-abdominal sepsis
Most likely organisms	Coliforms
Empiric treatment	Community acquired mild/moderate: Co-amoxiclav 1.2g tds iv plus Gentamicin 5mg/kg iv (max 480mg q24h). Hospital acquired or severe community acquired: Contact micro. Risk factors for MDRO: Call micro. Only if documented Hx of ESBL: Meropenem 1g tds iv. Seek review of Gentamicin.
In penicillin allergy	Ciprofloxacin 400mg q8-12h iv plus Gentamicin 5mg/kg q24h iv (max 480mg) plus Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg q12h iv plus Metronidazole 500mg q8h iv. If documented history of ESBL/ MDRO: Check sensitivities. If sensitive & no recent exposure: As above. Otherwise seek advice from microbiology.
Duration
Comments	If patient requires surgery, send specimen from theatre. See Vancomycin dosing. and Gentamicin dosing guidelines. Consider oral therapy when on clinical improvement, seek advice for options.Gentamicin dosing. If MUH / SIVUH Piperacillin-tazobactam 4.5g q8h iv plus Gentamicin 5mg/kg iv stat (max 500mg q24h), depending on severity. Seek review of Gentamicin.

Sepsis Neutropenic

Infection	Neutropenic sepsis
Most likely organisms	Aerobic gram negative rods, Gram positives usually associated with central venous catheters.
Empiric treatment	Piperacillin-tazobactam 4.5g q6h iv plus Gentamicin 5mg/kg q24h iv (max 480mg q24h). For line infection, septic shock, or MRSA colonisation: add Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg q12h iv. If documented Hx of ESBL: Meropenem 1g q8h iv. If confirmed ESBL: Meropenem 2g q8h iv.
In penicillin allergy	Ciprofloxacin 400mg q8h iv plus Gentamicin 5mg/kg q24h (max 480mg q24h) iv plus Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg q12h iv. ADD Metronidazole 500mg q8h iv if mucositis or GI symptoms present. If docemented Hx of ESBL/MDRO: Check sensitivities. If sensitive and no recent exposure: as above. Otehrwise seek advice from micro.
Duration
Comments	Avoid Gentamicin in multiple myeloma / renal impairment / platinum based chemotherapy, and use ciprofloxacin instead. Vancomycin dosing Please see local Neutropenic Sepsis guideline for more details. Seek daily review of Gentamicin. Gentamicin should not be required for more than 7 days Seek advice on oral options and duration of treatment.

Appendices

Appendix 1 Switching from IV to PO therapy
Appendix 2 Aminoglycoside monitoring
Appendix 3 Vancomycin
Appendix 4 Clostridium difficile diarrhoea
Appendix 5 MRSA
Appendix 6 Renal impairment, antibiotics
Appendix 7 IV preparations
Appendix 8 Prescribing Tips
Prophylaxis - Endocarditis
Prophylaxis - Meningitis
Prophylaxis - Post Splenectomy /Hyposplenic
Penicillin Allergy
SEPSIS.

Links

Content By Dr. Íomhar O' Sullivan 10/08/2010. Last review Dr. ÍOS 10/06/17.