3.4 Sepsis syndrome- Community acquired and Hospital acquired
| Type of Infection | First Line (with Dosage and Duration) |
Alternative First Line (with dosage and Duration) |
Comments |
|---|---|---|---|
| Sepsis – Community acquired without localization | Piperacillin-tazobactam 4.5g IV q6h | Cefoperazone- sulbactam 3g IV q12h | Add Doxycycline 100mg IV q12h if from endemic area for rickettsial infections. Duration of therapy will depend upon: • Finding focus of infection • Identification of infectious agent • Patient clinical status |
| Septic shock- community acquired infection without localization | Inj Meropenem 1g IV q8h + Inj Teicoplanin 400mg IV q12h for 3 doses followed by 6-12mg/kg IV q24h | Inj Imipenem- cilastatin 1g stat and 500mg IV q6h + Inj vancomycin 25 mg/kg IV stat followed by 15mg/kg q8-12h | Add Doxycycline 100mg q12h IV if from endemic area for rickettsial infections. Duration of therapy will depend upon: • Finding focus of infection • Identification of infectious agent • Patient clinical status If blood cultures are negative at 48 hours and if patient is improving, antibiotics can be de-escalated. |
| Hospital acquired sepsis (organ / device specific infection is dealt under HAI) | Meropenem 1g IV q8h Or Imipenem-cilastatin IV 1g stat and 500mg q6h | Meropenem 1g IV q8h + Polymyxin B 15-20 lakhs units IV stat, then 7.5-10 lakhs IV q12h Or Colistin 9MU IV stat, then 4.5 MU IV q12h | Hospital antibiogram is crucial for selecting empiric antibiotics for HAI. Duration of therapy will depend upon: • Finding focus of infection • Identification of infectious agent • Patient clinical status Add Vancomycin or Teicoplanin if risk for MRSA is noted. (eg central line infection suspected) Add Colistin or Polymyxin B if risk factors for CRO are present, which include history of carbapenem use in last 3 months, history of a positive carbapenem resistant organism culture in last 3 months. Need close renal monitoring and dose adjustment. Prefer polymyxin B over Colistin unless urine is suspected as a source of infection. Ceftazidime-avibactam +/- Aztreonam is a reserve drug to be used as targeted therapy after susceptibility reporting for carbapenem resistant Klebsiella species. Resistance among E.coli and Pseudomonas spp. is common and it is inactive against Acinetobacter spp., hence it is not recommended for empiric use. |
| Septic Shock - with localisation | See below for the recommendation based on the site of infection |
For common etiological agents of Sepsis syndrome- Community acquired and Hospital acquired, see Annexure B.3.4
Additional Information
The Golden Hour Management
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Measure lactate level. Re-measure if initial lactate level > 2 mmol/L.*
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Obtain blood cultures before administering antibiotics.**
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Administer broad-spectrum antibiotics.
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Begin rapid IV administration of 30ml/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L.***
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Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg ****
*"Time zero" or "time of presentation" is defined as the time of triage in the emergency department or, if presenting from another healthcare facility, from the earliest time-point in the treatment chart wherein, the patient had all the features consistent with sepsis.
**Two or more sets of blood cultures are recommended before initiation of any new antimicrobial in all patients with suspected sepsis.
***Hydroxyethyl starches (HESs) are not recommended for intravascular volume replacement in patients with sepsis or septic shock.
****Norepinephrineisthefirst-choicevasopressor.