University of Pennsylvania Health System Antimicrobial Use Guidelines- Sepsis

Graduate Medical Education

University of Pennsylvania Medical Center Guidelines for Antimicrobial Therapy

SEPSIS

Clinical Setting	Empiric Treatment	Likely Pathogens	Definitive Treatment	Dosage Regimen	Duration
Without Obvious Source Nonimmunocompromised Host
Unknown source	TMP/SMX + gentamicin	gram positive cocci gram negative bacilli	Based on culture results	TMP/SMX 8-10mg/kg/day TMP IV in 3-4 divided doses piperacillin-tazobactam 4.5 gm IV q 6 hours¹¹ metronidazole 500mg IV q 12 hours¹¹ gentamicin,tobramycin-see this link vancomycin see this link	Depends on clinical setting
if P. aeruginosa suspected¹ if B. fragilis possible¹¹ if IV catheter in place and patient critically ill²	piperacillin-tazobactam+ tobramycin add metronidazole¹¹ add vancomycin	gram positive cocci gram negative bacilli	Based on culture results		Depends on clinical setting
Intravenous Drug User	vancomycin + gentamicin³	gram positive cocci (including MRSA) gram negative bacilli	Based on culture results	vancomycin see this link gentamicin see this link	Depends on clinical setting
Without Obvious Source Neutropenic Host	see Neutropenia & Fever Section
Catheter-related⁴	cefazolin^5,6 + gentamicin	S. aureus	cefazolin⁶ OR nafcillin⁶	1gm IV q 8 hour 2gm IV q 4-6 hour	14 days (if catheter removed)⁷ OR 4 weeks (if catheter not removed)
		coagulase negative staphylococcus	vancomycin	see this link
		Enterobacteriaceae	TMP/SMX	8-10mg/kg/d TMP IV in 3-4 divided doses
		P. aeruginosa	piperacillin + gentamicin	4 gm IV q 6 hour see this link
		C. albicans	fluconazole or amphotericin B	400mg IV q 24 hour (switch to PO as soon as clinical improvement occurs) 0.5mg/kg/day IV see this link
Intra-abdominal source	ampicillin/sulbactam + gentamicin	polymicrobial	Based on culture results	ampicillin/sulbactam 1.5gm IV q 6 hours gentamicin see this link	Depends on clinical setting
Pneumonia related	see Pulmonary Infection Section
Urosepsis
Normal Host	ampicillin⁸ + gentamicin	Enterobacteriaceae	TMP/SMX	8-10mg/kg/day TMP IV/PO in 3-4 divided doses	14 days total⁹
		Enterococcus spp.¹⁰	ampicillin + gentamicin then amoxicillin	2gm IV q 6 hour peak conc. of 3-4 mcg/ml (consult pharmacokinetics) 500mg PO 8 hour
Immunocompromised host, chronic care facility resident, anatomic abnormality or gram negative bacilli on urine Gram stain	piperacillin + gentamicin	same as above + P. aeruginosa	piperacillin + gentamicin then levofloxacin	4 gm IV q 6 hour see this link 500mg PO q 24 hour

¹e.g.: necrotic skin lesions (ecthyma gangrenosum), burns, necrotizing or nosocomial pneumonias, nosocomial empyemas, etc.

²This is a clinical decision; guidelines include hemodynamic instability or evidence of serious infection

³If patient has septic physiology, use tobramycin instead of gentamicin

⁴Optimal treatment requires prompt removal of catheter

⁵If patient hemodynamically unstable, consider using vancomycin instead of cefazolin

⁶Use vancomycin if MRSA or penicillin allergy

⁷May want to follow with 14 days of oral therapy

⁸Ampicillin dose=2gm IV q 6 hours

⁹Can switch to oral therapy after clinical improvement occurs

¹⁰Review susceptibilities-30% of isolates multidrug resistant

¹¹Do not add metronidazole if using piperacillin-tazobactam; piperacillin-tazobactam already has activity against anaerobes

updated 9/28/04 by Lori LaRosa

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