Acute Care 25: Sepsis Guidelines*

Sepsis Criteria Identified:

Suspected infection
2 out of 4 criteria below:

- temperature > 100.4 or < 96.8
- heart rate > 100
- respiratory rate > 20 or PaCO₂ >32

Systolic BP < 90, MAP < 65 or > 20% decrease from baseline
Serum lactate > 2 mmol/L, oliguria, or MS change

Guiding Principles:

Emphasis is on early treatment with appropriate antibiotics and aggressive fluid resuscitation to restore adequate perfusion.
Central and arterial lines must not be placed routinely, but should be considered in patients who fail to respond.
Early consultation with critical care team

If patient on general care floor, call rapid response team.

Give appropriate antibiotics
Check labs
Give full bolus crystalloid 20 mL/kg over 30 minutes

Sepsis arrow down Severe Sepsis

Antibiotic Selection for Sepsis Protocol

Site	Suggested Antibiotics	Potential Medications with Dosages
Urinary Tract	Zosyn + (levofloxacin OR gentamicin) + vancomycin. If PCN allergic, use aztreonam in place of Zosyn	Zosyn 4.5 g IV q6h Levofloxacin 750 mg q24h Gentamicin 2 mg/kg IV q8h Vancomycin 1 g IV q12h Aztreonam 2 g IV q8h
Skin and Soft Tissue Infections	Zosyn (+ levofloxacin if gram- negative organisms suspected) + vancomycin. Add clindamycin if risk of toxin release.Toxin release strongly suggests surgical disease, eg, necrotizing fasciitis, gangrene, abscess.	Zosyn 4.5g IV q6h Levofloxacin 750 mg IV q24h Vancomycin 1 g IV q12h Clindamycin 900 mg IV q8h
Respiratory	Use Community Acquired Pneumonia (CAP) border set, with the addition of vancomycin for patients where MRSA risk possible and Linezolid for patients where MRSA is likely or strongly suspected.	See CAP antibiotic selection guideline.
Vascular Device Infection	Zosyn and Vancomycin. If PCN allergic, Aztreonam in place of Zosyn. One blood culture from catheter, one blood culture peripherally.	Zosyn 4.5 g IV q6h Levofloxacin 750 mg IV q24h Vancomycin 1 g IV q12h Clindamycin 900 mg IV q8h
Bacteremia/ Unknown Source	Zosyn + vancomycin. If PCN allergy, aztreonam + metronidazole in place of Zosyn. (If gram-negative organisms suspected consider double covering with levofloxacin or gentamicin)	Zosyn 4.5 g IV q6h Vancomycin 1 g IV q12h Aztreonam 2 g IV q8h Metronidazole 500 mg IV q6h
Abdominal	Zosyn + vancomycin. If PCN allergy, aztreonam + metronidazole in place of Zosyn.	Zosyn 4.5 g IV q6h Levofloxacin 750 mg IV q24h Vancomycin 1 g IV q12h Aztreonam 2 g IV q8h Metronidazole 500 mg IV q6h
Neurological	Meningitis/encephalitis: Ceftriaxone + vancomycin +/- ampicillin (if risk of Listeria) + dexamethasone (preferably given prior to antibiotics).	Dexamethasone 10 mg IV q6h X 2-4days Ceftriaxone 2 g IV q12h Vancomycin 1 g IV q12h Ampicillin 2 g IV q4h
Neurological	Abscess/Meningitis w/hardware: meropenem + vancomycin	Meropenem 2 g IV q8h Vancomycin 1 g IV q12h
Febrile Neutropenia	Vancomycin + Zosyn + Levofloxacin or Gentamycin. Typical etiology is gram- negative flora.	Vancomycin 1 g IV q12h Zosyn 4.5 g IV q6h Aztreonam (if PCN allergic) 2 g IV q8h Levofloxacin 750 mg IV q24h Gentamycin 2 mg/kg IV q8h
Diarrhea (Acute Syndrome)	Metronidazole + PO vancomycin. Vancomycin enema if oral vancomycin not possible	Metronidazole 500 mg IV q6h Metronidazole 500 mg PO q6h Vancomycin oral solution 250 mg PO q6h Vancomycin enema 1 g/500mL rectally q8h

Community Acquired Pneumonia Guidelines
Physician Orders	Nursing Guidelines/Orders
Routine patient orders: oxygen, cardiac monitor, IV access Obtain pneumonia severity index (PSI) score http://pda.ahrq.gov/clinic/psi/psicalc.asp	Oxygen at 2 to 4 L/min per nasal cannula or more to obtain SPO₂ > 90% Place on cardiac monitor Continuously monitor SPO₂, RR, HR, and intermittent BP readings. Insert at least one IV
Labs: Chem-8 Hemogram, platelets with differential Lactate Blood cultures X 2 Urinalysis, conditional UC ABG if critical patient Sputum culture and smear Urine antigen if PSI > 90	Draw rainbow of tubes, including a lactate on ice Obtain first blood culture with initial draw Obtain second blood culture 15 minutes after first blood culture obtained, or at a minimum, less than 1 hour after antibiotics started Draw ABG and place on ice; send to lab. May call Respiratory Therapy to obtain sputum sample.
Diagnostic Testing: ECG 12-lead; Chest X-ray PA and lateral (portable if critical patient)	If patient is monitored, the RN will accompany to x-ray.
Respiratory Medications: Albuterol nebulizer treatment Ipratropium nebulizer treatment	Obtain peak flow before and after administering nebulizer treatments.
Antipyretics: APAP or ibuprofen for temp > 101.5ºF	Consider rectal APAP if unable to swallow.
Antibiotics: For patients to be admitted: azithromycin 500 mg IV x 1 and one of the following: 1. ceftriaxone 1 g IV x 1 2. levofloxacin 500 mg IV x 1 3. levofloxacin 750 mg IV x 1 For patients to be discharged: azithromycin 500 mg oral x 1 in ED levofloxacin 500 mg oral x 1 in ED Discharge prescriptions: azithromycin (Z-pack) 250 mg oral levofloxacin 500 mg oral q day x 7 days	Infuse azithromycin over 60 min via infusion pump. Infuse ceftriaxone over 30 min via infusion pump. Infuse 500 mg IV over 60 min via infusion pump. Infuse 750 mg IV over 90 min via infusion pump. Antibiotics need to be started within 4 hours of arrival.
Admission: Admit to the hospitalist service in either medical or telemetry bed unless patient is in critical condition.	Complete admission note before transport.

Severe Sepsis Protocol Checklist*

Based on the Evaluation for Severe Sepsis Screening Tool
□ Does patient history suggest a new infection? If yes,
□ Does patient present with 2 or more new signs or symptoms of infection? If yes,
□ Does the patient have evidence of organ dysfunction due to the infection?

If answers to ALL screening elements are YES, initiate Severe Sepsis Protocol.
□ Determine time of presentation, which is equal to ED triage time or documentation (date/time) supporting diagnosis of severe sepsis in progress notes for non-ED admissions.

Quality Indicators to Measure

Sepsis Resuscitation Bundle—The goal is to perform all indicated tasks 100% of the time within the first 6 hours of identification of severe sepsis.
□ Measure serum lactate.
□ Obtain blood cultures prior to antibiotic administration.
□ Administer broad-spectrum antibiotic within 3 hours of ED admission and within 1 hour of non-ED admission.

Admission
In the event of hypotension and/or a serum lactate > 4 mmol/L
□ Deliver an initial minimum of 20 mL/kg crystalloid or an equivalent
□ Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg

In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L
□ Achieve a central venous pressure (CVP) ≥ 8 mm Hg
□ Achieve a central venous oxygen saturation (SvcO2) ≥ 70% or mixed venous oxygen saturation (SvO2) ≥ 65%.

Sepsis Management Bundle
Begin efforts to accomplish these goals immediately, but these items may be completed within 24 hours of presentation for patients with severe sepsis or septic shock:
□ Administer low-dose steroids for septic shock in accordance with a standardized ICU policy. If not administered, document why the patient did not qualify for low-dose steroids based upon the standardized protocol.
□ Administer recombinant human activated protein C (rhAPC ) according to standardized ICU policy. If not administered, document why patient did not qualify for rhAPC.
□ Maintain glucose control ≥ 70, but < 150 mg/dL
□ Maintain a median inspiratory plateau pressure (IPP) < 30 cm H2O for mechanically ventilated patients.

* Provided by Regions Hospital Emergency Department, St. Paul, Minnesota, 2010.

Acute Care 25: Sepsis Guidelines*

Edition 13-October 2011