Sepsis Management in Adults

Contents

Sepsis Management in Adults

If patient has all 3 of the below, initiate Severe Sepsis Orders (pre-printed order form):

1. Suspected Infection

2. 2 out of 4 of the below

•Temperature greater than 100.4°F (38°C) or less than 96.8°F (36°C)

•Heart rate greater than 90 bpm

•Respiratory rate greater than 20 or PaCO₂ less than 32 mmHg or mechanical

ventilation

•WBC greater than 12,000 or less than 4,000 mm³

3. Systolic BP less than 90 mmHg after 1500 ml fluid bolus OR

Serum lactate greater than or equal to 4 mmole/L

If patient meets the definition of severe sepsis and the APACHE II Score is greater than 25 (www.sfar.org/scores2/apache22.html), consider use of drotrecogin alfa by completing the Drotrecogin Alfa Assessment (pre-printed form).

Considerations for the Use of Drotrecogin Alfa

Absolute Contraindications:

- active internal bleed

- hemorrhagic stroke within 3 months

- intracranial or intraspinal surgery, or severe head trauma requiring hospitalization within 2 months

- trauma with increased risk of life-threatening bleeding

- presence of an epidural catheter

- intracranial neoplasm or mass lesion or evidence of cerebral herniation

- single organ dysfunction and recent surgery (within 30 days prior to treatment)

Relative Contraindications/Warnings:

- concurrent therapeutic heparin

- platelet count <30,000 x10⁵/L, even if platelet count is increased after transfusions

- INR >3

- GI bleed within 6 weeks

- administration of thrombolytic therapy within 3 days

- administration of oral anticoagulants, glycoprotein IIb/IIIa inhibitors or platelet inhibitors
(including aspirin >650mg) within 7 days

- ischemic stroke within 3 months

- intracranial arteriovenous malformation or aneurysm

- known bleeding diathesis

- chronic severe hepatic disease

- any other condition in which bleeding constitutes a significant hazard or would be particularly
difficult to manage because of its location

- pregnant or breast feeding

- age <18 years

- weight >135 kg

- chronic renal failure requiring hemodialysis or peritoneal dialysis

- acute pancreatitis with no established source of infection

- history of bone marrow, lung, liver, pancreas, or small bowel transplantation

- HIV infection in association with a last known CD4 cell count of ≤50/mm³

- The patient has received unfractionated heparin within 8 hours before infusion

- LMWH at a higher dose than recommended for prophylactic use within 12 hours before
infusion

- antithrombin III at a dose >10,000 units within 12 hours before infusion

- protein C within 24 hours before infusion

Ordering Drotrecogin Alfa

- all patients must be admitted to a special care unit

- a consult from an Intensivist Service or Infectious Diseases is
required

            - drotrecogin alfa should NOT be used in patients whose family, physician, or both are not in
              favor of aggressive treatment of the patient, or if an advanced directive to withhold life-
              sustaining treatment is present, or if the patient is in a moribund state in which death is
              perceived to be imminent

- The pre-printed assessment form and order set for drotrecogin alfa must be completed to
order drotrecogin. Pharmacy will not process any incomplete order sets.

Administration Considerations

- the drug will infuse for 96 hours once initiated

- the infusion should be discontinued for 2 hours prior to undergoing an invasive surgical
procedure or procedures with an inherent risk of bleeding

- once adequate hemostasis is confirmed, initiation may be reconsidered 12 hours after major
invasive procedures or restarted immediately after uncomplicated, less invasive procedures

- the drug must be administered through a dedicated intravenous line or a dedicated lumen of
a multilumen central venous catheter

Sepsis Antibiotic Selection Clinical Pathway

Suspected Source of Infection	Suggested Antibiotics
Unknown	Vancomycin per clinical pharmacy consult PLUS EITHER Piperacillin/tazobactam 4.5 grams IV q6h OR Imipenem 500 mg IV q6h
Intrabdominal Source	Ampicillin/sulbactam 3 grams IV q6h OR Piperacillin/tazobactam 3.375 grams IV q6h OR Imipenem/cilastatin 500 mg IV q6h OR Metronidazole 500 mg IV q8h PLUS Ciprofloxacin 400 mg IV every 12 hours Note: If risk factors for nosocomial or pseudomonas infection exist consider adding: Tobramycin—dosing per clinical pharmacy consult
Urinary Tract	Ciprofloxacin 400 mg IV q12h OR Piperacillin/tazobactam 3.375 grams IV q6h OR Imipenem/cilastatin 500 mg IV q6h OR Ampicillin 2 grams IV q6h PLUS gentamicin per clinical pharmacy consult.
Skin/Soft Tissue: Staphylococcus spp.	Vancomycin per clinical pharmacy consult OR Linezolid 600 mg IV q12h OR Daptomycin 4 mg/kg q24h OR Oxacillin 2 grams IV q4h if MRSA not suspected or ruled out
Skin/Soft Tissue: Clostridium perfringens (“Gas gangrene”), Group A Streptococcus	Penicillin G 6 million units IV q4h PLUS Clindamycin 900 mg IV q8h Aggressive surgical debridement recommended.

Skin/Soft Tissue: Polymicrobial Necrotizing fasciitis

Imipenem/cilastatin 500 mg IV q6h

Aggressive surgical debridement recommended.

Community Acquired Pneumonia – No Pseudomonas Risk Factors (see box below)

Excludes nursing home patients.

Ceftriaxone 1 gram (2 grams if > 80 kg) IV q24h

PLUS EITHER

Moxifloxacin 400 mg IV q24h

Azithromycin 500 mg IV q24h

Community Acquired Pneumonia – Pseudomonas Risk Factors (structural lung disease, >10mg prednisone/day, malnutrition)

Excludes nursing home patients.

Cefepime 2 grams IV q8h

Piperacillin/tazobactam 4.5 grams IV q6h

Imipenem 500 mg IV q6h

PLUS EITHER

Ciprofloxacin 400 mg IV q8h*

Aminoglycoside PLUS Azithromycin

Aminoglycosides – Gentamicin/tobramycin 5-7 mg/kg IV q24h**

Azithromycin 500 mg PO/IV q24h

*If Legionella is suspected , use aminoglycoside plus azithromycin

**Trough level for gentamicin and tobramycin once-daily dosing should be 0 mg/L – Consult the pharmacist for pharmacokinetic evaluation.

Nosocomial Pneumonia, includes healthcare-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP) (definitions available at

http://intranet.nebraskamed. com/departments/

antimicrobial_stewardship/

index.cfm) –

Known Risk Factors for Multidrug Resistant Bacteria (see below)

^ŦNOTE: see footnote if early onset (<5 days) HAP/VAP with no known risk factors

Vancomycin 15 mg/kg q12h* OR

Linezolid 600 mg IV q12h

PLUS

Cefepime 2 grams IV q8h OR

Piperacillin/tazobactam 4.5 grams IV q6h OR

Imipenem 500 mg q6h

PLUS**

Gentamicin 5-7 mg/kg IV qday*** OR

Tobramycin 5-7 mg/kg IV qday*** OR

Ciprofloxacin 400 mg IV q8h

*Trough levels for vancomycin should be approximately 15 mg/L – Consult the pharmacist for pharmacokinetic evaluation.

** If Legionella is suspected , use an aminoglycoside plus azithromycin 500 mg IV qday.

***Trough level for gentamicin and tobramycin once-daily dosing should be 0 mg/L – Consult the pharmacist for pharmacokinetic evaluation.

Risk Factors for Multidrug Resistant Bacteria