Optimize INITIAL antibiotic dosing in septic patients
Overview
Sepsis is now the leading cause of 30-day hospital readmissions, spurring hospitals to continue improving care of sepsis patients. Updated sepsis guidelines will also help lead this charge...
Management steps
Fluids
Continue "tried and true" therapies, 30 mL/kg of crystalloid within 3 hours, broad-spectrum antibiotics started within one hour, etc. But fine-tune fluid and antibiotic strategies.
- Most heart failure and kidney disease patients need the 30 mL/kg bolus.
- But reassess all patients after the bolus, additional fluids may be harmful once patients are volume resuscitated.
- Expect physicians to continually assess volume status using passive leg raises or stroke volume assessments. Guidelines are catching up with the evidence, central venous pressure monitoring doesn't have a mortality benefit.
Antibiotic dosing
Optimize INITIAL antibiotic dosing strategies. For example, use the highest approved amount for beta-lactam first doses, such as cefepime 2 grams or piperacillin/tazobactam 4.5 grams. Also infuse the first dose of an extended infusion beta-lactam regimen over 30 minutes instead of several hours. If IV access is limited, consider diluting ceftriaxone, cefepime, or meropenem in about 10 to 20 mL, and give it IV push over about 3 minutes. Keep in mind, there's no proof these strategies improve outcomes. But they may help meet antibiotic time windows and avoid potential underdosing caused by increased volume and clearance in some patients.
- Lean toward saving empiric gram-negative "double coverage" for septic SHOCK after considering patient history, antibiograms, etc.
- Think about using a shorter antibiotic course, such as less than 7 to 10 days, for a stable patient who experiences a rapid recovery.
- Verify your hospital utilizes a sepsis protocol and tracks outcomes. It's not clear which sepsis screening tool is best, but using a protocol for early recognition and treatment may decrease mortality.
References
- Rhodes A, Evans LE, Alhazzani W, Levy MM, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017 Mar;45(3):486-552.
- Evans L, Rhodes A, Alhazzani W, Antonelli M, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247.
- Dellinger RP, et al. A Users' Guide to the 2016 Surviving Sepsis Guidelines. Crit Care Med. 2017 Mar;45(3):381-385.
- Howell MD, Davis AM. Management of Sepsis and Septic Shock. JAMA. 2017 Feb 28;317(8):847-848.
