Sepsis — Red Zone — Antibiotic Recommendations for Patients with Septic Shock or Sepsis-Associated Organ Dysfunction — Clinical Pathway: Emergency Department, Inpatient and PICU

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Red Zone — Antibiotic Recommendations for Patients with Septic Shock or Sepsis-Associated Organ Dysfunction

Use Sepsis Order Set

1st antibiotic within 1 hour
Remaining antibiotics within 3 hours
Healthy patient
No central line
 
 
Patient with any of the following:
  • Central line
  • Immunocompromised, non-oncology
  • Receiving immunosuppressive medications
    (other than chemotherapy) [ 1 ]
  • Recent hospitalization (> 4 days within 2 months)
  • Long term care facility resident
 
 
Oncology patient
 
 
Hemodynamically unstable requiring vasoactive therapy AND/OR being admitted to or in an ICU for shock
 
 
 
 
All other oncology patients with sepsis
 
 
  1. Ceftriaxone [ 2 ] [ 3 ]
  2. Vancomycin
  3. Metronidazole if concern for intra-abdominal source
  1. Cefepime [ 2 ] [ 3 ]
  2. Vancomycin
  3. Metronidazole if concern for intra-abdominal source
  1. Meropenem [ 2 ]
  2. Vancomycin
  1. Cefepime [ 2 ] [ 3 ]
  2. Vancomycin
  3. Add metronidazole if concern for intra-abdominal source
Administer Antibiotics in the Order Listed
Consider Additional or Alternative Antimicrobials in the Following Clinical Scenarios
MDRO History
(e.g., ESBL, CRE, or RGN under MDRO tab OR culture positive for one of these organisms in the past 1 year)		 Modify empiric choice based on prior susceptibilities, consider ID consult
Patient Already on Broad-spectrum Antibiotics [ 4 ] 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 individual patient circumstances
Toxin-mediated Syndrome Clindamycin
Influenza Osteltamivir
Risk of Fungemia Caspofungin [ 5 ]

Re-assess the need for continued antibiotic therapy at 24-48 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 patient with septic shock
    • Patient with blood stream infections (strongly encouraged, particularly in cases of S. aureus bacteremia), CNS infections, and suspected/documented fungal infections
1.
Common Immunosuppressive Medications
  • Oral or SQ methotrexate ≥ 5 mg
  • Prednisone 2 mg/kg/day or ≥ 20 mg daily (> 2 weeks)
  • Cyclophosphamide
  • Rituximab
  • Mycophenolate mofetil
  • Azathioprine
  • Tacrolimus
  • Sirolimus
  • Cyclosporine
  • Anakinra
  • Infliximab
  • Etanercept
  • Adalimumab
  • Canakinumab
2.
  • Allergy to First-Line β-Lactam, Assess Need for Alternative
  • If alternative needed, ciprofloxacin replaces cephalosporin;
    for suspected intra-abdominal infection with or without
    concern for CNS infection, ciprofloxacin should be administered with metronidazole
  • For oncology patients with hemodynamic instability who cannot receive meropenem – discuss with ID
3.
Antibiotic OK to IV push over 5 minutes OK to give IM
Amikacin   x
Cefepime x x
Ceftriaxone x x
Clindamycin   x
Meropenem x  
Do not give IV push if extended IV infusion over 3-4 hours is ordered
4.
  • Broad Spectrum Antibiotics
    • Any regimen including ceftriaxone, ceftazidime, cefepime, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or aztreonam alone or in combination with vancomycin or clindamycin
5.
  • Risk of Fungemia
    • No clear guidelines for when to begin empiric antifungal therapy exist in non-neutropenic patients, but empiric caspofungin can be considered in the presence of known risk factors and severe illness. Known risk factors include: broad-spectrum antibiotic exposure, neutropenia, central venous catheter, steroid use, poor gut integrity, TPN, and bone marrow transplantation. Please call Infectious Diseases to discuss.