Sepsis, N/IICU — Yellow Zone Antibiotics — Clinical Pathway: ICU and Inpatient

Suspected Sepsis Clinical Pathway — N/IICU

Yellow Zone Antibiotics — Suspected Infection, No Shock

Community onset sepsis
in a infant ≤ 56 days
Hospital onset sepsis in an infant < 7 days, no central line or history of fetal or neonatal surgical intervention
  • Any of the following
    • Infant ≥ 7 days hospitalized > 48 hrs
    • History of fetal or neonatal surgical intervention
    • Central line
Infant with suspected
intra-abdominal infection
Febrile Infant Pathway
Ampicillin
Gentamicin
Cefepime
Vancomycin
Concern for CNS infection
e.g., VPS
Yes
No
Cefepime
Metronidazole
Piperacillin/
tazobactam
Consider vancomycin initiation until cultures are verified to be negative for pathogens susceptible to vancomycin (at 24-36 hours)
Antibiotics That Can Be Given Via IV/IM Push
Antibiotic OK to IV Push Over 5 min OK to Give IM
Cefepime Yes Yes
Ceftriaxone Yes Yes
Ceftazidime Yes Yes
Clindamycin No Yes
Meropenem Yes No
Please see the CHOP Formulary for complete drug information.
Consider Additional or Alternative Antimicrobials for the Clinical Scenarios Below
Clinical Scenario Recommendations Comments
MDRO History Modify empiric choice based on prior susceptibilities, consider ID consult
  • MDRO history examples:
    • ESBL, CRE, or RGN under MDRO tab
    • or
    • Culture positive for one of these organisms in the past 1 year
Child Already on Broad-spectrum Antibiotics
  • Choice of antibiotic(s) and/or antifungals may be individualized, considering previous antibiotic exposures and suspected source of infection
  • Discuss with ID as needed based on child's circumstances
  • Common broad-spectrum antibiotic include any of the following:
    • Ceftriaxone
    • Ceftazidime
    • Cefepime
    • Piperacillin-tazobactam
    • Ciprofloxacin
    • Levofloxacin
    • Aztreonam
    • Meropenem
    • Imipenem
  • Vancomycin and clindamycin are not considered broad-spectrum antibiotics when administered as monotherapy
Influenza Add oseltamivir
Risk of HSV Acyclovir
  • Indicated for all infants ≤ 21 days; consider for infants 22-56 days old with any of the following risk factors:
    • Maternal vesicles and/or fever within 48 hrs before or after delivery
    • Postnatal oral HSV exposure
    • Vesicles or mucous membrane ulcers
    • Abnormal mental status, seizure
    • Hypothermia
    • Pleocytosis or RBCs in CSF
    • Leukopenia
    • Thrombocytopenia

Re-assess the need for continued antibiotic therapy at 24-36 hours based on culture data, results of imaging studies, and clinical course.

If cultures are negative and low suspicion for bacterial infection → discontinue antibiotics.

If focal source of infection is identified, tailor antibiotics based on clinical syndrome and/or culture data, if available.

  • Consider ID consult if:
    • Concern for culture-negative sepsis to discuss duration of antibiotics and/or additional diagnostic evaluation
    • History of MDRO and/or current MDRO identified
    • Severely immunocompromised child with septic shock
    • Child with bloodstream infections (strongly encouraged, particularly in cases of S. aureus bacteremia), CNS infections, and suspected/documented fungal infections