Sepsis

(not shock, NO Persistent hypotension + Lactate >2)
qSOFA: ≥2 = high risk (RR ≥22, SBP ≤100, AMS).
SIRS: ≥2 = systemic inflammation (Temp >38/<36, HR >90, RR >20, WBC >12K/<4K).

  • CC: Fever, chills, weakness, AMS, hypotension

  • PP: Tachycardia, fever, dysuria/cough/abdominal pain, decreased PO

  • PN: No focal neuro deficits/chest pain

  • pertinent SHx: IVDU, recent hospitalization, immunocompromised

  • Etiology: Systemic infection with organ dysfunction

  • risk factors: Elderly, DM, CKD, cancer, devices/lines

  • initial DATA: CBC (WBC↑), CMP (Cr/LFT↑), lactate (↑), blood cultures, UA, CXR, procal

  • pending DATA: Blood/urine cultures, CT if source unclear

  • prior data:

  • MEDS: recent antibiotic exposure, immunosuppression, anticoagulation

  • COURSE:

Plan:

  • Antibiotics:

    • Vancomycin 15–20 mg/kg IV q8–12h + Cefepime 2 g IV q8h

    • Abdominal concern: add Metronidazole 500 mg IV q8h

    • ESBL risk: Meropenem 1 g IV q8h + Vancomycin

  • IV fluids/sepsis protocol ~30 cc/kg

  • f/u Blood cultures

  • Trend CBC, CMP, lactate, cultures

  • Trend fever curve/hemodynamics

  • f/u Source control/workup (UA/CXR/CT)

  • PT/OT eval

  • Escalate ICU/pressors if persistent hypotension or rising lactate

  • PO step-down: Levofloxacin 750 mg PO daily OR Ciprofloxacin 500–750 mg PO BID OR TMP-SMX DS 1–2 tab PO BID depending source/cultures

  • Duration: typically 7–14 days depending source

ANTIBIOTICS

  • Sepsis (broad)-> (Vanc + Cefepime) , Abdominal concern (+ Flagyl), ESBL risk: (Meropenem + Vanc)

  • Nec Fasc -> Vancomycin + Meropenem + Clindamycin (Meropenem = Cefepime + Metronidazole)

  • CAP-> Ceftriaxone + Azithro (5) ((MRSA/Pseudomonas risk: Cefepime + Vanc ± Azithro (7)))

    • PO: Augmentin + Doxy/Azithro OR Levo, (MRSA: Linezolid)

  • HAP -> Cefepime + Vanc ((septic: Meropenem + Vanc)) (7)

    • PO: Levo/Cipro (psedo) if susceptible + MRSA PO: Linezolid

  • Aspiration Pneumonia- > Ceftriaxone ± Flagyl (7)((Severe: Cefepime + Flagyl)), Abscess/necrosis: 2–6 weeks

    • PO: Augmentin ((Severe Levo + Flagyl))

  • UTI / Pyelonephritis -> Ceftriaxone ((septic: Cefepime)), ESBL: Meropenem , Pyelo: 7–10 days, Complicated/septic: 10–14 days

    • PO -> - TMP-SMX or Levo or Cipro

  • Urosepsis -> Cefepime +VANC ((Shock/ESBL risk: Meropenem)) 7–14 days

    • PO -> - TMP-SMX or Levo or Cipro and (MRSA: Linezolid)

  • Cholangitis / Cholecystitis -> Stable: Ceftriaxone + Flagyl ((Sicker/pseudomonas risk: Cefepime + Flagyl)), Septic shock/ESBL: Meropenem 4–7 days

    • PO-> Augmentin ((Severe Levo + Flagyl))

  • Diverticulitis / Intraabdominal Infection-> Stable: Ceftriaxone + Flagyl 4–7 days((Severe: Cefepime + Flagyl)), ESBL/shock: Meropenem complicated 7–14 days

    • PO-> PO-> Augmentin ((Severe Levo + Flagyl))

  • SBP (Spontaneous Bacterial Peritonitis) -> Ceftriaxone ((septic Cefepime)), ESBL risk: Meropenem (5 day)

    • PO-> TMP-SMX ((Severe Cipro))

  • Cellulitis -> IV: Ceftriaxone

    • PO-> Cephalexin (Penicillin allergy: Clinda) 5–7 days

  • Purulent / Abscess -> Vanc

    • PO Step-down TMP-SMX , or doxy or Linezolid 5–10 days

  • Diabetic Foot Infection -> Mild PO: Cephalexin ± Doxy, sever-> IV: Vanc + Cefepime + Flagyl ((ESBL risk: Meropenem + Vanc)),

    • PO-> Augmentin or Levo + Flagyl

  • Osteomyelitis -> CTX + Vanc ((Polymicrobial: Vanc + Cefepime + Flagyl))

    • PO Linezolid or TMP-SMX or levo or clinda 4–6 weeks

  • Septic Arthritis -> Vanc + Ceftriaxone ((IVDU/pseudomonas risk: Vanc + Cefepime))

    • PO-. TMP-SMX 2–4 weeks

  • Meningitis -> Vanc + Ceftriaxone ((Age >50/immunocompromised: add Ampicillin)) , Healthcare-associated: Vanc + Cefepime

    • Typically prolonged IV therapy (ID consult) - Pneumococcal: 10–14 days Meningococcal: ~7 days

  • Bacteremia / Sepsis Unknown Source-> Vanc + Cefepime ((Abdominal concern: add Flagyl)), ESBL risk: Meropenem + Vanc

    • PO MRSA bacteremia: -> prolonged IV , Sometimes Linezolid

    • Gram-negative bacteremia:- > Levo or Cioro, or tmp-smx 7–14 days

  • Infective Endocarditis -> Vanc + Ceftriaxone ((Prosthetic valve: Vanc + Cefepime))

    • Mostly prolonged IV therapy Usually 4–6 weeks IV

  • Necrotizing Fasciitis / Fournier Gangrene -> Vanc + Meropenem + Clinda OR Vanc + Cefepime + Flagyl + Clinda

    • PO Rare early PO , later Augmentin or TMP-SMX or Linezolid (ID) 2–3+ weeks

  • C. diff Colitis -> PO vanc or Fidaxomicin ((Fulminant :PO Vanc + IV Flagyl))

    • Usually 10 days

  • Neutropenic Fever - > Cefepime+ vanc (ESBL/shock: Meropenem)

    • PO-> Depends ANC recovery/cultures , Levo

  • PID (Pelvic Inflammatory Disease) -> Ceftriaxone + Doxy + Flagyl

    • PO -> Doxy + Flagyl 14 days total

  • Bite Wounds (Human/Animal) -> IV severe: Unasyn

    • Po-> Augmentin or Clinda 5–7 days

  • Dental / Odontogenic Infection -> - Unasyn OR Ceftriaxone + Flagyl

    • Po-> Augmentin or Clinda 5–7 days

  • ESBL risk → prior ESBL, heavy FQ exposure, LTCF/recurrent hospitalization → use Meropenem

  • MRSA risk → prior MRSA, HD, IVDU, purulence, healthcare exposure, severe sepsis → add Vancomycin (or Linezolid/Daptomycin)

  • Pseudomonas risk → structural lung disease, prior Pseudomonas, prolonged/recent antibiotics, ICU/healthcare exposure → use Cefepime, Zosyn, or Meropenem ± double coverage if critically ill