Blood / Sepsis

Microbiological specimens
Blood Culture 2-3 samples

  • For line infection blood cultures should be taken both peripherally and from all lines /lumens.
  • Line tips should be sent if infected line is removed.
  • Other samples as indicated under specific organ system investigations.
  • The choice of agent should take into account the patient’s risk for C. difficile infection.

Where source of septicaemia is known, please refer to guidance under relevant body systems.

Infection: Presence of microorganisms in a normally sterile site.

 Bacteraemia: Cultivable bacteria in the bloodstream.

 Systemic Inflammatory Response Syndrome (SIRS):

SIRS is the systemic response to a wide range of stresses and is defined in adult patients as Two or more of:

  • Temperature >38ºC or <36ºC
  • Heart rate >90 beats per minute
  • Respiratory rate > 20 breaths per minute or PaCO2< 4.3kPa
  • WBC > 12 x 109 cells/L or < 4 x 109 cells/L

 Sepsis: Sepsis is defined as SIRS associated with proven or clinically suspected infection; Sepsis Pathway.

Severe sepsis: Sepsis associated with organ dysfunction (distant from infection site), hypoperfusion or hypotension (systolic BP <90mmHg, MAP <70mmHg or reduction of 40mmHg from baseline).

Septic shock: Sepsis with hypotension requiring pressor therapy despite adequate fluid resuscitation.  In addition there are perfusion abnormalities that may include lactic acidosis, oliguria, altered mental status and acute lung injury.

Septicaemia:  Sepsis associated with bacteraemia.

Diagnosed – organ dysfunction with ≥ 2 of the following:
WCC <4 or >12 x 109/L
Temp <36°C or >38°C
Heart rate >90bpm
Respiratory rate >20/min or PaCO2 <4.3kPa
Refer to Trust Guidelines and pathway on Surviving Sepsis.

Common Pathogen(s)
Multiple pathogens.

Antibiotic – 1st line

Amoxicillin 2g q8h IV
plus
Metronidazole 500mg q8h IV [if intrabdominal sepsis suspected].
Plus
Gentamicin (click here for full gentamicin policy) 
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70 years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.

5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min  or
3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20%  over ideal body weight – use adjusted body weight

MRSA/ MSSA colonised:
Replace Amoxicillin with Flucloxacillin 2g q6h IV (MSSA) or Vancomycin IV (dosed as per trust vancomycin guideline) (MRSA).

 

2nd Line

Non-serious penicillin allergy (e.g rash) or patients with liver cirrhosis at risk of hepatorenal syndrome:
Cefuroxime 1.5g q8h IV
plus 
metronidazole 500mg q8h IV
+/- 
Gentamicin (click here for full gentamicin policy) 
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.

5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min  or
3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight – use adjusted body weight

If history of anaphylaxis to penicillin –
Teicoplanin 10mg/kg q12h for 3 doses IV then 10mg/kg q24h IV (round to nearest 200mg or 400mg vial)
plus 
metronidazole 500mg q8h IV
plus
Gentamicin (click here for full gentamicin policy) 
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70year or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.

5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min  or
3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight – use adjusted body weight

Comment
All hospital admissions MUST receive a screen for MSSA/ MRSA as per local policy.

All patients with MSSA or MRSA bacteraemia must receive an echocardiogram and at least 14 days of IV treatment with clearance blood culture after 48h.

Duration of therapy – as per clinical response

Common pathogen(s)
Gram positive, gram negative organisms and anaerobes

Pregnant:

Cefuroxime 1.5g IV q8h 1,2
Plus
Metronidazole 500mg IV q8h 1,2
Plus
Gentamicin for 24-48hours only if no improvement with cefuroxime and metronidazole or severe sepsis 1,2(click here for full gentamicin policy) 
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.

5mg/kg IV q24h for 24-48hours only  (max 500mg): if <70 years and CrCl≥30mL/min  or
3mg/Kg IV q24h for 24-48hours only (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation. Use booking in weight or if patient is obese ie. 20% over ideal body weight – use adjusted body weight

Consider Listeriosis – consider specific treatment with microbiologist

 

Post Partum (Not Breast Feeding):

Amoxicillin  IV 2g q8h 2,3
Plus
Metronidazole 500mg q8h IV [if intrabdominal sepsis suspected] 2
Plus 
Gentamicin (click here for full gentamicin policy) 2,3
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.

5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min  or
3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration

CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation. If patient is obese ie. 20% over ideal body weight – use adjusted body weight

 

Post Partum (Breast Feeding): 

Co-amoxiclav IV 1.2g q8h 2,4
 Plus 
Gentamicin one stat dose 2,3(click here for full gentamicin policy) 
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70 years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.

5mg/kg IV one stat dose (max 500mg): if <70 years and CrCl≥30mL/min  or
3mg/Kg IV one stat dose (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight – use adjusted body weight

 

Comment

Gentamicin – Due to the limited data and the theoretical risk of ototoxicity and nephrotoxicity, the use of parenteral gentamicin in pregnancy is reserved except for the treatment of serious or life-threatening conditions unresponsive to standard antibiotic therapy. If parenteral gentamicin is required in pregnancy, close monitoring of maternal serum concentrations is advised, with the dose being adjusted as necessary.

References

  • Toxbase https://www.toxbase.org/Exposure-in-pregnancy/ <accessed 23/4/15>
  • Briggs G, Freeman R et al, Drugs in pregnancy and lactation. 9th ed.
  • Schaefer C, Peters P, et al. Drugs during pregnancy and lactation. 3rd ed.
  • UKMI,lactation

Microbiological specimens
Blood Culture 2-3 samples

  • For line infection blood cultures should be taken both peripherally and from all lines.
  • Line tips should be sent if infected line is removed.
  • Other samples as indicated under specific organ system investigations.
  • The choice of agent should take into account the patient’s risk for C. difficile infection.

 

Line-associated Septicaemia (peripheral and central cannulae) and Tunnel track infections (Hickman line)

Duration of therapy 2 weeks

Common Pathogen(s)
Staphylococcus aureus;
Hickman/ long lines may have Enterobacteriaceae.

Antibiotic – 1st line

Vancomycin IV (dosed as per trust vancomycin guideline)

Add stat dose or once daily dose of Gentamicin while awaiting culture results in patients with central line. Use of Gentamicin post 48h must be discussed with Microbiologist during working hours.(click here for full gentamicin policy)
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70year or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.

5mg/kg IV one stat dose (max 500mg): if <70 years and CrCl≥30mL/min  or
3mg/Kg IV one stat dose (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight – use adjusted body weight

Comment
Remove line. Switch to Flucloxacillin if isolate proves to be MSSA.

Discuss all suspected cases of neutropenic sepsis with Haematologists/acute oncology team and Microbiologists
Microbiological specimens
Please refer to individual Trust protocols and procedures for Haematology and Oncology.
Avoid Gentamicin in patients recieiving Platnuium based chemotherapy, use Meropenem (in haematology patients), piperacillin-tazobactam alone can be used in oncology in this group of patients.

 

Treatment of fever or sepsis in neutropenic patients

Fever of 38.3°C or more on one occasion, or 38.0°C or more sustained for 1 hour in a patient at risk of neutropenia e.g.post chemotherapy.

Never wait for results before starting IV antibiotics.

Refer to Trust Policy for Management of Infection in Neutropenic Patients.

Common Pathogen(s)
Gram positive pathogens; Gram negative pathogens which can lead to shock, multiorgan failure and death

Antibiotic – 1st line

Piperacillin-tazobactam 4.5g q8h IV
plus
Gentamicin (omit gentamicin in all oncology patients- unless signs of severe sepsis – see oncology policy CORP/PROT/323) (click here for full gentamicin policy)
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70year or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.

5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min  or
3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight – use adjusted body weight

In renal impairment, use one single dose of Gentamicin only.
Review Gentamicin at 48 hours unless otherwise instructed.
Local decision to use combination of piperacillin-tazobactam and gentamicin outside NICE clinical guidance 151 on Neutropenic Sepsis due to local resistance pattern.

 

2nd Line/penicillin allergy of all severity as per Christie policy-link
Meropenem 1g IV 8 hourly

Monitor closely if previous penicillin anaphylaxis.

Comment
Discuss all suspected cases of neutropenic sepsis with Haematologists and Microbiologists
Identify source of infection.
Patients with pelvic/rectal/tooth symptoms NOT receiving Piperacillin-tazobactam, should have Metronidazole 400mg PO 8 hourly (500mg IV 8 hourly) added to cover anaerobic organisms.