Acute Care 25: Sepsis Guidelines*
Sepsis Criteria Identified:
- temperature
> 100.4 or < 96.8
- heart rate > 100 - respiratory rate > 20 or PaCO2 >32
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Guiding Principles:
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If patient on general care floor, call rapid response team. |

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Sepsis
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 |
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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 |
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Labs:
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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.
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.