Hull & East Yorkshire Hospitals NHS Trust Guidelines for the Empiric Treatment of Sepsis in Adults – Review

Date 11/2009

Advice
• ID consultant on for referrals via ID
secretaries on CHH 3005, 3016 or 4131
(Mon-Fri, 9am-5pm only)
• On-call microbiology consultant via
switchboard (After 5pm, all referrals must
be made by a consultant only)
Consider oral therapy if:
• No severe sepsis (see central box to right)
• No meningitis, endocarditis, abscess,
osteomyelitis or septic arthritis
• No malabsorption and oral route intact
• Patient does not have febrile neutropenia
Patient with symptoms and/or signs of infection Definition of allergy: Rash or anaphylaxis
Assess presence/source of sepsis using clinical judgement and criteria below
Definition of sepsis: Symptoms and/or signs of infection plus at least 2 or more of: Streamlining
Temperature <36ºC or >38ºC Once sensitivities are available, adjust
Pulse >90/minute antibiotics accordingly and ‘streamline’ to the
Respiratory rate >20/minute narrowest spectrum regimen possible
White cell count <4 or >12 x 109/L (Discuss with ID/micro if needed)
Definition of severe sepsis:
Sepsis associated with organ hypoperfusion (i.e. new confusion, hypoxia (PaO2 <8.0kPa), liver
dysfunction, oliguria (<30 mls/hour) and metabolic acidosis) or hypotension (sBP <90mmHg)
Definition of septic shock:
Alert antibiotics
These can only be prescribed for inpatient treatment (except
Severe sepsis with hypotension (sBP <90mmHg) not responding to fluid resuscitation (40 mls/kg) prophylaxis) after discussion with ID/micro: azithromycin,
ceftazidime, cefuroxime, ceftriaxone, cotrimoxazole, IV
sodium fusidate, imipenem, levofloxacin, linezolid,
® ®
Investigations - All patients to have FBC, BCP, CRP, blood culture(s) & CXR. When taking blood meropenem, moxifloxacin, Synercid , Tazocin (except
cultures, do not take via cannulae, use a strict sterile technique and fill bottles with 10mls of blood each neutropenic sepsis), tigecycline and all IV antifungals
Please provide detailed information on all microbiology/virology request forms (except neutropenic sepsis)

No sepsis Sepsis Severe sepsis/septic shock

Unless patient has suspected meningitis, Unless patient has suspected meningitis, endocarditis, abscess, All patients should receive
endocarditis, abscess, osteomyelitis or septic osteomyelitis or septic arthritis, antibiotics for non-severe illness will antibiotics for severe illness
arthritis, either no antibiotics or antibiotics for usually suffice. Some patients may be deemed severe by clinical
non-severe illness will usually suffice judgement and should be given antibiotics for severe illness

Prescriptions must state an indication and stop/review date and be reviewed daily. Check BNF for drug interactions. Stop antibiotics if there is no evidence of infection. Seek advice for life
or limb-threatening infection, endocarditis, meningitis, in renal impairment/dialysis (see renal unit protocols) and with drug monitoring. If gentamicin is used, refer to gentamicin guidelines

Community or Severity/ COPD Pneumonia UTI Skin, soft tissue, Hepatobiliary Gastroenteritis Intraabdominal Meningitis Gram + Gram –
hospital- allergy (Treat for 5 (Use CURB65 to (Treat simple UTI bone & joint (Consider (House patient (Consider (Inform bacteraemia bacteraemia
days and assess severity in in  for 3 days) (Refer fasciitis to surgical review) in side-room) surgical review) Public Health if (Consider deep (Consider
acquired review) community-acquired) plastics urgently) meningococcal) source) source)

Non-severe None or CURB65 = 0/1: Oral/IV Send urine Oral or IV Oral ciprofloxacin None required Oral ciprofloxacin See below See below See below
oral/IV amoxicillin 1g/8h culture first flucloxacillin 1g/6h 500mg/12h 500mg/12h plus
(See below for CURB65 = 2: Above
IV alternative if amoxicillin plus oral/IV clarithro-
Oral trimethroprim oral metronidazole
not given) 500mg/8h mycin 500mg/12h 200mg/12h 400mg/8h
Severe Oral/IV CURB65 3: IV co-amoxiclav IV flucloxacillin IV co-amoxiclav Oral ciprofloxacin IV co-amoxiclav IV cefotaxime Streptococci: IV IV co-amoxiclav
(And IV amoxicillin IV co-amoxiclav 1.2g/8h ± IV 2g/6h (Add IV 1.2g/8h ± IV 500mg/12h 1.2g/8h plus IV 2g/6h (Add IV amoxicillin 2g/6h 1.2g/8h ± IV
1g/8h 1.2g/8h plus IV gentamicin clindamycin 600mg/6h gentamicin 5mg/kg (400mg/12h if IV) metronidazole amoxicillin 2g/6h Staphylococci: IV gentamicin
Community- alternative if not
clarithromycin 5mg/kg once with plus IV benzylpenicillin
once with level at 6- (Add oral 500mg/8h ± IV if ≥55 years old) flucloxacillin 2g/6h 5mg/kg once with
given under 2.4g/4h plus IV Blind therapy: Both of
acquired non-severe) 500mg/12h level at 6-14h 14h (Add IV metronidazole gentamicin 5mg/kg level at 6-14h
ciprofloxacin the above
metronidazole 400mg/8h if once with level at
400mg/12h in fasciitis MRSA: Use regimen
and septic shock) 500mg/8h in liver Clostridium difficile 6-14h
likely) below
abscess)
Penicillin Oral Non-severe: Oral/IV Severe only: IV Oral/IV clindamycin Severe only: IV Discuss with Severe only: IV Chloramphenicol IV teicoplanin IV ciprofloxacin ±
st
allergy (Doses doxycycline clarithromycin ciprofloxacin ± IV ciprofloxacin ± IV ID/micro if allergic ciprofloxacin plus 50mg/kg daily in 4 12mg/kg/12h for 1 IV gentamicin
as elsewhere 100mg/day Severe: IV cefotaxime gentamicin gentamicin to ciprofloxacin IV metronidazole ± divided doses; day and then
unless stated) (Discuss with 2g/8h plus IV IV gentamicin discuss patient 12mg/kg/day with
ID/micro if IV clarithromycin with ID/micro trough level at day 7
required)
Non-severe Oral co- Oral co-amoxiclav Send urine Oral or IV Oral ciprofloxacin None required. Oral ciprofloxacin See below See below See below
(See below for IV amoxiclav 625mg/8h (1.2g/8h if culture first flucloxacillin 1g/6h 500mg/12h Send stool for 500mg/12h plus
alternative if not 625mg/8h IV) Oral trimethroprim Clostridium difficile oral metronidazole
Hospital-
given) (1.2g/8h if IV) 200mg/12h and await result 400mg/8h
acquired
Severe Oral co- IV co-amoxiclav IV co-amoxiclav IV clindamycin IV co-amoxiclav Oral/Ng IV co-amoxiclav Discuss with IV teicoplanin IV co-amoxiclav
(Infection amoxiclav 1.2g/8h plus IV 1.2g/8h plus IV 600mg/6h plus oral 1.2g/8h plus IV metronidazole 1.2g/8h plus IV ID/micro 12mg/kg/12h for 1st 1.2g/8h plus IV
(And IV
occurring >48h alternative if not 625mg/8h or gentamicin 5mg/kg gentamicin ciprofloxacin 750mg/ gentamicin 5mg/kg 400mg/8h metronidazole day and then gentamicin
post-admission given under non- IV co- once with level at 6- 5mg/kg once with 12h (400mg/12h if IV) once with level at 6- (500mg/8h if IV) 500mg/8h plus IV 12mg/kg/day with 5mg/kg once with
(Add IV teicoplanin
or following severe; do not amoxiclav 14h (Add IV level at 6-14h 12mg/kg/12h for 1 stday 14h (Add IV Send stool for gentamicin 5mg/kg trough level at day 7 level at 6-14h
use gentamicin 1.2g/8h metronidazole metronidazole Clostridium once with level at NB remove/change
recent in non-severe)
and then 12mg/kg/day if
500mg/8h in patient is MRSA +) 500mg/8h in liver difficile 6-14h any peripheral and/or
admission) aspiration) abscess) CV lines
Penicillin Oral/IV Oral/IV ciprofloxacin Severe only: IV Non-severe: Severe only: IV Discuss with Severe only: IV Discuss with Discuss with ID/micro IV ciprofloxacin
allergy (Doses ciprofloxacin ciprofloxacin plus Oral/IV clindamycin ciprofloxacin plus ID/micro if allergic ciprofloxacin plus IV ID/micro if allergic to plus IV
as elsewhere metronidazole plus IV
IV gentamicin IV gentamicin to metronidazole gentamicin
teicoplanin gentamicin
unless stated)