A Quick Guide to Sepsis Antibiotics

A Quick Guide to Sepsis Antibiotics

A Micro-Learning Activity by: Catherine Burgin, BSN, RN Duke University School of Nursing N664 Summer 2024

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Click on "Objectives" to get started! As you go through each page, you can use the next or back arrow buttons to move through the learning activity. If at any point you want to return to this page, click the home button in the top right corner. You can also click on any of the topics below to jump to that section.

Choosing Antibiotics

Objectives

Parting Pearls

Is it Sepsis?

Quiz

Basic Sepsis Bundle

Let's Get Started!

Objectives

The objectives for this micro-learning activity include:

• Helping the learner identify signs and symptoms of sepsis

• Helping the learner choose initial orders for a patient based off of identified sepsis criteria

• Helping the learning choose antimicrobials for initial treatment of sepsis

• Identifying some helpful tips and treatment pearls based on current sepsis guidelines

What is Sepsis?

Sepsis can be defined as the body's inability to regulate appropriately in response to an infecetion. Severity of sepsis can range from sepsis to septic shock.

Schmidt et al., 2024

Is it Sepsis? How do we know?

Diagnostics such as vital signs and basic labwork can clue healthcare providers in on the presence of a septic process. Healthcare institutions use different screening tools for all of their patients to identify the potential for sepsis and it's severity.

Click each (+) to learn more about each screening tool and click again to close.

SIRS Criteria

Presence of 2 or more of these criteria indicate a positive SIRS screen, and should raise suspicion of sepsis

MEWS Criteria

The Modified Early Warning System (MEWS) assigns point values to different vital sign ranges and levels of consciousness. The higher the MEWS score, the higher the potential need for ICU level of care and the higher the predicted mortality.

Your patient screened positive for sepsis

Now What?

Labs and Diagnostics

Fluid Resuscitation

Patient Monitoring

Click on each picture above for the current SCCM Recommendations

Society of Critical Care Medicine, 2021; Schmidt et al., 2024

Antibiotics in Sepsis

Antibiotics should be started within an hour of identifying possible sepsis in a patient. So how do you decide which ones to give and why? Let's take a look at 3 different considerations for the type of antibiotics we choose. Always remember to assess your patient's medication allergies.

Are we worried about MRSA?

Broad Spectrum Coverage

PseudomonasCoverage

Broad Spectrum Antibiotics

Broad spectrum antibiotics are the antibiotics that every patient is going to receive. They might not stay on that exact regimen once the cultures result, but it gets them started with fighting off the organism causing their sepsis.

What makes it "Broad Spectrum"?

Broad spectrum just means that the agent covers a wide variety of organisms - both gram negative and gram positive.

Things to Consider

Broad spectrum antibiotics are very powerful and can cause many side effects. It is important to consider aspects like allergies, kidney and liver function, and potential side effects/interactions when choosing an antibiotic.

Click here to keep going

Which antibiotics are we talking about?

While several antibiotics can be considered broad spectrum, these are considered to be "preferred" due to their coverage for the most commonly seen infections

• Cephalosporins: ceftriaxone (Rocephin), cefepime (Maxipime
• Beta-lactams: piperacillin/tazobactam (Zosyn)
• Carbopenems: meropenem (Merrem)

Which one do I choose?

Any of these medications are good choices. Things to be considered when choosing an agent include allergies and renal function. For example, a patient with a known penicillin allergy should not receive Zosyn, but any other the other agents are sufficient.

Dosing Information

On to the next ones

Schmidt et al., 2024

What about MRSA?

Not everyone needs MRSA coverage. Reasons to suspect MRSA include:

• recent hospitalization
• history of previous MRSA infections
• patients presenting with severe sepsis/septic shock
• residents of nursing homes or group homes

What do we give?

Dosing for MRSA Agents

Give your broad spectrum coverage selection AND

• Vancomycin (1st Line) or
• Daptomycin or
• Linezolid

Vancomycin is the recommended first line agent, with daptomycin or linezolid as secondary options if patients have contraindications/allergies to taking vancomycin.

On to the next one!

Fowler & Holland, 2024

I'm Concerned about Psuedomonas...

Pseudomonas is very similar to MRSA in that not every patient needs coverage for this infection. The populations at risk for pseudomonas are also very similar to the populations at risk for MRSA. These populations include

• those living in a nursing home or group home setting,
• recently hospitalized patients,
• patients with implanted medical devices
• patients with weakened immune systems

Antibiotic selection for pseudomonas is very simple. Depending on what you chose for broad spectrum coverage, you might not have to add anything extra. The regimen would look something like this: Broad Spectrum + Vancomycin ± Psuedomonas

Dosing Information

Pseudomonas Agents

Schmidt et al., 2024

Onward

Things to Remember

• Initiate the sepsis bundle as soon as sepsis is identified - the goal is antibiotics within 1 hour
• Blood cultures should be drawn before antibiotics are started
• If a source cannot be identified and cultures don't show any bacterial growth, consider discontinuing antibiotics.
• ALWAYS verify patient allergies prior to starting antibiotics
• Take into consideration a patient's renal function when dosing antibiotics
• Consult pharmacy (if available) for dosing help
• If your facility has an infectious disease service, their input could be helpful as well

Quick Quiz!

Let's see how much you learned about sepsis!

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Click Here for References

Labs and Diagnostics

Blood Cultures

Two sets, each from a different site. Ideally drawn BEFORE administration of antimicrobials

Complete Blood Count (CBC)

Lacti Acid

Complete Metabolic Panel (CMP)

Rule out electrolyte abnormalities and identify organ dysfunction (renal and hepatic)

Source Identification Tools

Diagnostics such as chest x-rays, echocardiogram, and urinalysis can help narrow down a source of infection to help tailor treatment after initial resuscitation

Pseudomonas Agents

• Cefepime
• Meropenem
• Piperacillin/Tazobactam
• Ciprofloxacin
• Aztreonam

Patient Monitoring

Vital signs should be obtained at minimum every hour and trended. If any vital signs are abnormal, more frequent readings are advised.

If initial lactate level is elevated (>2.0), then level should be trended every 2 hours until it has returned to normal.

Urine output should be monitored hourly to identify signs of renal dysfunction. Mental status should also be monitored to identify deteriorating status.

References

• Fowler, V., & Holland, T. (2024). Clinical approach to Staphylococcus aureus bacteremia in adults. UpToDate. UpToDate. https://www-uptodate.com.proxy.lib.duke.edu/ contents/clinical-approach-to-staphylococcus-aureus-bacteremia-in-adults?search=gram%20positive%20cocci%20treatment&source=search_result&selectedTitle=1%7E150& usage_type=default&display_rank=1#H4
• Gilbert, D., Chambers, H., Saag, M., & Pavia, A. (Eds.). (2024). Ciprofloxacin dosing. Sanford Guide. Antimicrobial Therapy, Inc.
• Schmidt, G., Mandel, J., & Bell, T. (2024). Evaluation and management of suspected sepsis and septic shock in adults. UpToDate. UpToDate. https://www-uptodate-com.proxy.lib.duke.edu/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults?search=sepsis%20management&source=search_result &selectedTitle=1%7E150&usage_type=default&display_rank=1#H2634735011
• Society of Critical Care Medicine. (2021). Surviving sepsis guidelines. Society of Critical Care Medicine. https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult-Patients

MRSA Coverage Information

Dosing is sometimes weight based, and there are renal considerations, especially with vancomycin. Vancomycin is also given as a larger initial dose followed by lower doses based on serum trough levels. As always, hospital pharmacy can be a great resource for questions if available.

Schmidt et al., 2024; Fowler & Holland, 2024

Pseudomonas Agent Dosing

Dosing for agents used as broad spectrum agents are the same for pseudomonas coverage. Forumlations may be different depending on the facility.

Schmidt et al., 2024; Gilbert et al., 2024

Broad Spectrum Dosing

Dosing may very depending on facility. Always verify patient allergies prior to antibiotic administration. Consider renal/hepatic function as well. When in doubt, pharmacy is always a great resource, if available.

Schmidt et al., 2024;

Fluid Resuscitation

The current Society of Critical Care Medicine (SCCM) recommendations for fluid resuscitation in sepsis patients suggest administering a 30mL/kg bolus of isotonic crystalloids over 3 hours.

• If a patient has a history of heart failure and/or is showing signs of fluid overload, it is ok to administer half of the calculated fluid volume and reassess before continuing

If a patient continues be hypotensive or show signs of poor perfusion after the administration of the fluid bolus, start the patient on vasopressors (norepinephrine is the first choice)