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First-line antibiotic therapy for adult medical patients attending or being admitted to hospital

NB: Always give rst dose promptly


(
Infective Exacerbation of COPD (with purulent sputum)
doxycycline 200mg stat, then 100mg od orally OR amoxicillin 500mg tds orally For Type II Decompensated Respiratory Failure - seek Respiratory team advice, amoxicillin 1g tds iv

Sepsis / Severe Sepsis Screening Tool


Are any two of the following SSI criteria present?
Temperature < 36 or > 38.30C Heart rate > 90bpm WCC > 12 or < 4 x 109/l Respiratory rate > 20/min Acutely altered mental state Hyperglycaemia in the absence of diabetes

Community acquired pneumonia


(only with consolidation on chest x-ray; document CURB-65 score)

If yes, patient has SSI


Does your patient have a history or signs suggestive of a new infection? For example:
Cough/sputum/chest pain Abdo pain/distension/diarrhoea Line infection Endocarditis Dysuria Headache with neck stiffness Cellulitis/wound infection/septic arthritis

Mild - Moderate

amoxicillin 500mg tds orally & clarithromycin* 500mg bd orally (*MUST review at 48 hours) (If penicillin allergy clarithromycin 500mg bd orally) OR Severe (i.e. 3 or more of CURB-65: confusion, urea>7, RR>30, diastolic BP<60, age>65yr) benzylpenicillin 1.2g qds iv & clarithromycin 500mg bd iv (if penicillin allergy levooxacin 500mg bd iv & clarithromycin 500mg bd iv) Review at 48 hrly intervals, change to oral amoxicillin & clarithromycin. (Patient able to swallow/absorb, temp improving) If pneumonia of severity needing admission to Critical Care use levooxacin 500mg bd iv & benzylpenicillin 1.2g qds iv (If penicillin allergy levooxacin 500mg bd iv & clarithromycin 500mg bd iv) If urinary sepsis also likely, consider adding gentamicin 160mg stat iv (while awaiting microbiology)

( (

Simple UTI (dysuria but no systemic symptoms)


(take MSU) trimethoprim 200mg bd orally for 3 days

UTI with systemic symptoms (fever, rigors, loin pain)


(take MSU) ciprooxacin 500mg bd orally OR If recent urological intervention or long-term urinary catheter use ertapenem 1g od iv Review when micro results available Severe sepsis of unknown origin (including MEWS score r 3), take blood cultures, then start antibiotics immediately, consider amoxicillin 1g tds iv, metronidazole 400mg tds iv & gentamicin 160mg stat iv, seek advice where appropriate.

If yes, patient has SEPSIS

Any signs of organ dysfunction?


SBP < 90mmHg or MAP < 65mmHg Lactate > 2mmol/l New need for oxygen to keep SpO2 > 90% Platelets < 100 x 109/l Creatinine > 177 mmol/l

Cellulitis
Mild - Moderate Severe ucloxacillin 1g qds orally (clindamycin 450mg qds orally if penicillin allergic or ucloxacillin failure)

Urine output < 0.5ml/kg/hr for 2 hrs INR > 1.5 or aPTT > 60s Bilirubin > 34mol/l

benzylpenicillin 1.2g qds iv (clindamycin 450mg qds iv if penicillin allergic) PLUS ucloxacillin 1g qds iv NB: If rapidly progressive, +/- shock, severe disproportionate pain consider Necrotising Fasciitis. This is a surgical emergency (must seek senior advice), usual antibiotic therapy is clindamycin and meropenem

( (

Probable bacterial meningitis (must be discussed with senior medical staff)


cefotaxime 2g qds iv

Neutropenic Sepsis
(Neutrophils <1.0x109/L) Tazocin 4.5g tds iv (discuss with SpR Haem) (meropenem 1g tds iv if penicillin allergic)

For complex cases please contact duty microbiologist including if patient recently discharged from hospital, allergy to rst line regimen, infections in pregnancy. Always check for contra-indications, drug interactions, and dosage modication in renal and hepatic impairment.

Feb 2007

If no, treat for SEPSIS: Oxygen Blood cultures IV antibiotics Fluid therapy Reassess for SEVERE SEPSIS with hourly observations
Survive SEPSIS www.survivesepsis.org
Sabina Moolla August 2007 Version: 1

If yes, patient has SEVERE SEPSIS Start SEVERE SEPIS CARE PATHWAY

Document to be kept in patients notes


Patient name..........................PID. ....................... Date .................. Ward ....................

6 Hour Resuscitation Bundle (assisted care)


Patient name..........................PID. ....................... Date .................. Ward .................... Systolic BP <90mmHg or MAP <65mmHg or a fall of > 40mmHg from baseline
No

Severe Sepsis Care Pathway - First Hour Care Duties


Yes YES
Apply Severe Sepsis Screening Tool
: h

Could this patient have sepsis?

Negative

Reassess patient Apply appropriate management plan

YES

No

Lactate > 4 mmoI/I ?

Severe sepsis, no shock Ensure management plan is documented in notes Ensure hourly obs taken, recorded and acted upon. REASSESS frequently!

Start the clock

Time

Initial

Sepsis Six

Reason not done or result

Septic shock present!


Confirm first hour care duties complete Apply Early Goal

YES

No

1. Oxygen: high flow 15l/min via nonrebreathe mask. Target saturations > 94%
2. Blood cultures: take at least one set plus all relevant blood tests eg FBC, U&E, LFT, clotting, glucose.
Consider urine/sputum/swab samples.

Directed Therapy

Time achieved

Initial

Reason not done or result

1. Ensure Critical Care attend urgently (if not already) 2. Ensure patient has received adequate fluid resuscitation: boluses of 20ml/kg 0.9% saline or Hartmanns to a max of 60ml/kg 3. If still shocked (low BP/low urine output/
high lactate) insert central venous catheter under USS guidance (only if competent; otherwise seek help)

3. IV antibiotics as per trust guidelines


4. Fluid resuscitate: if hypotensive give boluses of 0.9% saline or Hartmanns 20ml/kg up to a max of 60ml/kg 5. Serum lactate and Hb: (ABG analyser: A&E/ICU/Ward 20) Ensure Hb > 7g/dl

6. Catheterise and commence fluid balance

4. Aim to achieve CVP 8-12mmHg with Care Check CVP Monitor 5. Take heparinised sample from central line (use ABG syringe): check ScvO2 > 70% 6. Ensure Hb > 7g/dl: consider transfusion if necessary 7. Consider noradrenaline if still shocked or dobutamine if ScvO2 < 70%
No Sig ............................. Bleep / ID Card No. ..............
6 hour time check: Name .............................................. Designation .....................................
Survive SEPSIS www.survivesepsis.org
Sabina Moolla August 2007 Version: 1

Plus
a. Call Outreach Team if appropriate

b. Discuss with SpR or Consultant

One hour time check: all steps done? Name .............................................. Designation .....................................
Survive SEPSIS www.survivesepsis.org
Sabina Moolla August 2007 Version: 1

Yes

All steps complete?

Yes

No

Sig ............................ Bleep / ID Card No. ..........................

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