Septicaemia Definitions 1 Term Definition Bacteraemia Systemic Inflammatory response (SIRS) Sepsis Bacteria that can be cultured from the blood stream The systemic response to a wide range of stresses. Criteria include two or more of the following: Temperature >38 o C or < 36 o C Heart rate > 90 beats/min Respiratory rate > 20 breaths per min, or Paco 2 < 32 mm Hg (KPa?) WBC > 12,000 / mm 3 or < 4,000 / mm 3, or > 10% immature (band) forms Systemic response to infection associated with proven or clinically suspected infection Severe sepsis or Sepsis syndrome Septic shock Toxic shock syndrome (TSS) - Staphylococcal TSS - Streptococcal TSS Sepsis associated with dysfunction of organ(s) distant from the site of infection, hypoperfusion, or hypotension. Sepsis with hypotension that, despite adequate fluid resuscitation, requires pressor therapy. In addition, there are perfusion abnormalities e.g. lactic acidosis, oliguria, altered mental status, and acute lung injury Acute febrile illness characterised by a generalised erythematous skin rash due to in vivo production of a toxin, often asymptomatic or unnoticed infection by S. aureus strains capable of toxin production. In addition to SIRS like symptoms early features also include conjunctival, oropharingeal, and vaginal hyperemia; vomiting, diarrhoea and myalgia. The most common symptoms include temp >40 o C, hypotension and difuse erythroderma with descamation 1 to 2 weeks after onset. The term streptococcal toxic shock syndrome has been suggested for patients with S. pyogenes (Group A streptococcus) infection with hypotension and multiorgan failure as occurs in staphylococcal TSS Streptococcal TSS is sometimes referred to as Toxic shock-like syndrome (TSLS). Urgent : 1- Replete Intravascular volume 2- Source control if possible 3- Empiric antibiotics Although restricting the use of antibiotics, and particularly broad-spectrum antibiotics, is important for limiting superinfection and for decreasing the development of antibiotic resistant pathogens, patients with severe sepsis or septic shock warrant broad-spectrum therapy until the causative organism and its antibiotic susceptibilities are defined. For detailed information please refer to Surviving sepsis campaign
Septicaemia 2 IT IS ESSENTIAL TO SEND BLOOD CULTURES (IDEALLY PRE-ANTIBIOTICS) Alternative regimens Septicaemia of unknown origin NOTE: this section does not apply for patients with suspected Meningitis For treatment of suspected meningitis please refer to the relevant section Community acquired Patient stable Community acquired But Patient Unstable or Hospital acquired NOT septic shock Neutropaenic patients HIGH RISK All patients excluded from low risk protocols (see full febrile Neutropenic guidelines). All patients with signs of severe sepsis; Temp >38 or <36 o C + pulse > 90/min in the presence of any of the following; Respiratory rate >20/min Systolic BP <90mmHg or reduction of 40mmHg from baseline Acute confusion Oliguria (<80mls urine in 4 hours) Metabolic acidosis (ph <7.35) Ampicillin 1g IV TDS + Gentamicin** 5mg/kg IV OD +Metronidazole 500mgIV TDS + Gentamicin** 5mg/kg IV OD If no response at 48 hours or deterioration earlier ADD Teicoplanin 10mg/kg IV to nearest 100mg (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours. If no response after a further 48 hours stop tazocin and gentamicin and ADD Meropenem 2g IV TDS CONSIDER ANTIFUNGAL THERAPY Teicoplanin and gentamicin levels ARE required discuss with consultant Microbiologist If penicillin allergy but no anaphylaxis Meropenem 1-2g IV TDS Anaphylaxis to penicillin: + Gentamicin** 5mg/kg IV OD If penicillin allergy but no anaphylaxis Meropenem 2g IV TDS If no response at 48 hours or deterioration earlier ADD (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours Anaphylaxis to penicillin Contact consultant Microbiologist + Aztreonam 1g IV QDS + (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours.+/- Gentamicin ** 5mg/kg IV OD Teicoplanin and gentamicin levels ARE required discuss with consultant Microbiologist If known or suspected MRSA or ESBL carrier isolate in a side room contact the Infection Control Team on extension 6774 or bleep 2364 during working hours Monday to Friday Protective isolation on a positive pressure side room is essential Contact the Infection Control Team on extension 6774 or bleep 2364 during working hours Monday to Friday. If Central Line in situ please refer to Catheter related blood stream infection (CBRSI) section for targeted therapy * No need to monitor Teicoplanin levels routinely; unless acute renal failure aim for: 10 to 40 mg/l
Septicaemia 3 IT IS ESSENTIAL TO SEND BLOOD CULTURES (IDEALLY PRE-ANTIBIOTICS) Septicaemia with suspected or known origin (Not Septic Shock) NOTE: this section does not apply for patients with suspected Meningitis For treatment of suspected meningitis please refer to the relevant section Peripheral line Take blood cultures and swab from venflon site then give antibiotics Central & tunneled lines Take blood cultures peripherally and through the line then start antibiotics Intra abdominal Infections: Perforated gut or biliary sepsis Flucloxacillin 1-2g IV QDS Review after 48hours, of no positive culture results consider stopping antibiotics For full guidance please refer to CRBSI (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours. Teicoplanin levels ARE required send trough level before 4 th dose For full guidance please refer to CRBSI Ampicillin 1g IV TDS +Metronidazole 500mg IV TDS If four quadrant peritonitis or patient unstable: If Penicillin allergy or known MRSA carrier: (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours. Teicoplanin levels ARE required send trough level before 4 th dose Teicoplanin* +Gentamicin** as per first choice loading doses 12 hours apart then every 24 hours loading doses 12 hours apart then every 24 hours If known or suspected MRSA/ESBL or AmpC carrier isolate in a side room contact the Infection Control Team on extension 6774 or bleep 2364 during working hours Monday to Friday Urinary tract See relevant section of the Urinary Tract Infections guidance and treat as for Pyelonephritis, Hospital acquired, recurrent UTI complicated See relevant section of the Respiratory Tract Infections guidance and treat as for severe hospital Respiratory tract or community acquired pneumonia as appropriate * No need to monitor Teicoplanin levels routinely; unless acute renal failure aim for: 10 to 40 mg/l
Septicaemia 4 IT IS ESSENTIAL TO SEND BLOOD CULTURES (IDEALLY PRE-ANTIBIOTICS) Septic Shock Syndromes NOTE: this section does not apply for patients with suspected Meningitis For treatment of suspected meningitis please refer to the relevant section Septic shock Not severe allergy: Meropenem 1-2g IV TDS Severe allergy: (sepsis syndrome unresponsive to (Max 500mg) Teicoplanin 10 mg/kg IV (max 800mg per adequate fluid resuscitation) If MRSA risk or line related septicaemia ADD: dose) for 3 loading doses 12 hours apart then every 24 hours (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours Teicoplanin levels ARE required send trough level before 4 th Teicoplanin levels ARE required send dose trough level before 4 th dose CONSIDER ANTIFUNGAL THERAPY If high risk of invasive fungal infection Toxic Shock Suspected Group A streptococcus / Flucloxacillin sensitive S. aureus(mssa) Suspected Flucloxacillin resistant S. aureus (MRSA) septicaemia Flucloxacillin 1-2g IV QDS + Benzylpenicillin 1.2-2.4 g IV QDS + Clindamycin 1.2 g IV TDS Consider IVIg (Held at Haematology lab) Targeted therapy should be sought if specific microbe isolated contact Microbiology consultant (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours Teicoplanin levels ARE required send trough level before 4 th dose (aim for 20-40 mg/l) Clindamycin 1.2 g IV TDS + Daptomycin^ 4 6 mg/kg IV OD Consider IVIg (Held at Haematology lab) Teicoplanin* as per first choice Or with Microbiology approval: Daptomycin^ 4 6 mg/kg IV OD Or Linezolid** 600mg IV BD Alternative to Gentamicin if renal impairment with Microbiology approval: Aztreonam 1g IV QDS Targeted therapy with cultures should be the norm discuss with Microbiologist Standard immunomodulatory dose for adults is 2 g/kg (set empirically). Two daily doses of 1 g/kg each. In general the 2-day infusion is not associated with more adverse reactions than the 5-day infusion. The 2-day dosage schedule may prevent rapid deterioration in patients with acute conditions If Group A strep or MRSA likely Patient should be isolated in a side room Isolation required Contact the Infection control team for advice on extension 6774 or bleep 2364 during working hours Monday to Friday. ^Rhabdomyolysis has been reported, monitor CPK weekly during treatment = high risk agent for Clostridium difficile associated diarrhoea (CDAD) **Linezolid is licensed for a maximum of 28 days, bone morrow toxicity is frequent needs monitoring with FBC
Septicaemia 5 IT IS ESSENTIAL TO SEND BLOOD CULTURES (IDEALLY PRE-ANTIBIOTICS) Septicaemia specific conditions Sepsis in IV drug users Sepsis in patients with previous Splenectomy Fungaemia Post splenectomy (asplenia) Likely agents: Pneumococci (90%), meningococci, H. influenzae type b, also at risk of fatal malaria, babesiosis and Capnocytophaga spp. Flucloxacillin 1-2g IV QDS + Gentamicin** 5 mg/kg IV OD Ceftriaxone 2 g IV BD Remove catheter if present Caspofungin 70mg IV loading dose then 50mg IV OD (Requires Microbiology approval) Targeted therapy can be attempted once sensitivities are known Treat with antifungal therapy for 14 days after first negative blood culture [daily blood cultures until first negative set] Ceftriaxone 2 g IV BD (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours + Gentamicin** 5 mg/kg OD IV Teicoplanin levels ARE required send trough level before 4 th dose Anaphylaxis to penicillin: Levofloxacin 750mg IV OD Or Aztreonam 1g IV QDS + (maximum 800mg daily) for 3 loading doses 12 hours apart then every 24 hours Contact Microbiology to discuss treatment options Anaphylaxis to penicillin: Levofloxacin 750mg IV OD or Aztreonam 1g IV QDS Plus Isolation may be required Contact the Infection control team Risk assess Protective isolation on a positive pressure side room is essential. Contact the Infection Control Team Isolation required Contact the Infection control team for advice on extension 6774 or bleep 2364 during working hours Monday to Friday. Endocarditis Seek advice from Microbiology (Working party guidelines) * No need to monitor Teicoplanin levels routinely; unless acute renal failure aim for: 10 to 40 mg/l
Septicaemia 6 IT IS ESSENTIAL TO SEND BLOOD CULTURES (IDEALLY PRE-ANTIBIOTICS) Septicaemia with identified Pathogen Flucloxacillin sensitive S. aureus (MSSA) septicaemia Deep seated infection e.g. endocarditis, osteomyelitis etc to be ruled out and treated accordingly Flucloxacillin 2 g IV QDS Plus Rifampicin or Fusidic acid when tissue penetration is an issue (osteomyelitis, Prosthetic Joint Infections, Abscesses, endocarditis) Teicoplanin 10mg/kg IV to nearest 100mg (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours Teicoplanin levels ARE required send trough level before 4 th dose (aim for 20-40 mg/l) Standard precautions required Flucloxacillin resistant S. aureus (MRSA) septicaemia Deep seated infection e.g. endocarditis, osteomyelitis etc to be ruled out and treated accordingly Teicoplanin 10mg/kg IV to nearest 100mg (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours Teicoplanin levels ARE required send trough level before 4 th dose (aim for 20-40 mg/l) With Microbiology approval: Daptomycin^ 4 6 mg/kg IV OD or Linezolid** 600mg IV BD NOTE: Linezolid licensed only up to 28 days If known or suspected MRSA/ESBL or AmpC carrier isolate in a side room contact the Infection Control Team on extension 6774 or bleep 2364 during working hours Monday to Friday ** Patients with impaired renal function CrCl < 60 ml/min (Cockcroft-Gault Clearance from Biochemistry. Sex, age and weight need to be stated on the form) use a reduced dose of 3mg/kg ^Rhabdomyolysis has been reported, monitor CPK weekly during treatment **Linezolid is licensed for a maximum of 28 days, bone morrow toxicity is frequent needs monitoring with FBC