Sepsis (Post-operative)

Sepsis is a medical emergency – see Hospital HealthPathways.
Vital signs provide useful clues. At least two of the following should be present:
- Temperature > 38°C or < 36°C
- Heart rate > 90 beats per minute
- Respiratory rate > 20 breaths per minute or PaCO₂ < 32 mm Hg
- WBC count > 12 x 10⁹/L or < 4 x 10⁹/L or the presence of immature neutrophils (toxic granulation).
This is a useful starting point only and requires interpretation. In patients with signs of septic shock, early consultation with ICU is recommended.
Diagnosis: take appropriate cultures, a minimum of 2 sets of blood cultures and urine cultures, and a culture of the site.

cefuroxime

IV 1.5 g every eight hours

AND

gentamicin

IV 5 to 7 mg/kg ideal body weight initially, then see dosing guidelines.

AND

metronidazole

IV 500 mg every twelve hours

High oral availability – prescribe orally unless GI absorption is compromised or patient is nil by mouth.
Metabolised by unknown pathways. (fe = 0.1).

Severe penicillin allergy – consult with Infectious Diseases/Clinical Microbiology

If multi-drug resistant organism isolated or suspected give

piperacillin+tazobactam

(Tazocin™)

IV 4 g/500 mg every six hours

If still on piperacillin+tazobactam beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
fe (piperacillin) = 0.8, fe (tazobactam) = 0.6, consider adjusting dose if CrCl reduced.

meropenem

IV 1 g every eight hours

Meropenem rapidly and significantly reduces sodium valproate concentrations. Concomitant administration may precipitate seizures in patients with a pre-existing seizure disorder. Discuss alternative antibiotic options with Infectious Diseases/Clinical Microbiology.
If still on meropenem beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
fe = 0.7, start with full dose initially then consider extending dose interval and/or decreasing dose for subsequent doses if CrCl is reduced (< 30 mL/min). Consult pharmacist.

flucloxacillin

IV 2 g every six hours

fe = 0.7, consider adjusting dose if CrCl reduced.
Risk of hepatotoxicity is increased in females, patients > 55 years old, high doses, and courses longer than 14 days duration.

PLUS

gentamicin

IV 5 to 7 mg/kg ideal body weight initially. See dosing guidelines

Mild penicillin allergy

cefazolin

IV 2 g every eight hours

PLUS

gentamicin

IV 5 to 7 mg/kg ideal body weight initially, then see dosing guidelines.

Topic Code: 99283