Sepsis: Approach and Empiric Tx

End-organ-damage OR hypotension, PLUS fever, tachycardia, tachypnoea, WCC++

Overall Approach
1. CULTURES first. Two bloods. Urine, sputum, wounds as appropriate.
2. Antibiotics
3. Start fluid resus. NS 300ml iv bolus if poor peripheral circulation, confusion, oliguria OR lactate>4mmol/l.
4. Correct Hypotension with target >90/65. Fluid resus then consider Noradrenaline or dopamine infusion.
5. Maintain O2 and glucose.
6. Consider corticosteroids if unresponsive to fluids and vasopressors.
7. Tx according to culture results and choose abx appropriately.
8. If fever persists for >4 days, seek ID Consultant.

Unknown source.
Adults: Flucloxacillin 2g iv qid + Gentamicin 7mg/kg iv stat.
Febrile, Neutropenic: Piperacillin+Tazobactam 4+0.5g iv tid (Tazosin). Add vancomycin if in shock, has MRSA, or high MRSA incidence in ward.

Child, Meningitis Not Excluded (Playing it very safe!)
Over 6 months, Cefotaxime 50mg/kg iv qid.
Under 6 months, add Amoxycillin 50mg/kg iv qid PLUS Vancomycin 30mg/kg iv bd infused.

GIT source?
Metronidazole 500mg iv bd, Amoxicillin 1g iv qid, Gentamicin 6mg/kg*.
Beyond 3 days, stop all above, use Piperacillin+Tazobactam 4+0.5g iv tid (Tazosin).

Intravascular Device?
Flucloxacillin 2g iv qid PLUS Gentamicin 7mg/kg*
MRSA likely, replace fluclox with Vancomycin 1.5g iv bd inf.


*see post on gentamicin dosing.

Urinary Tract Infections

Other than mild cystitis, MSU culture before starting abx if possible. Consider blood cultures if pyrexic and unwell with NV (suspect sepsis). In men, consider urology review (congenital malformations) if recurrent. Nitrates in urine has a very poor sensitivity (<50%). Consider risk of trimethoprim in women of childbearing age! Cranberry products reduce symptoms but do not resolve UTI!

Cystitis: Dysuria, Polyuria, Urgency, Nocturia, Cloudy, Urine, WBC & RBC.

• .Trimethoprim 300mg po sid 3/7.
• If pregnant, or Trimethoprim doesnt work, use Cephalexin 500mg po sid 5/7.
• Resistant to all, then Norfloxacin 400mg po BD 3/7.

Pyelonephritis: NV, 38C+, abdo/flank pain, white cells, MCS+.
For mild cases (low fever, no sepsis, no vomiting), treat as per cystitis - trimethoprim then norfloxacin. If septic, give Gentamicin 6mg/kg iv stat PLUS Amoxycillin 2g iv qid. Repeat in 24h if eGFR > 60. If low eGFR, liase ID reg. Max 3 doses genta.

Recurrent UTI: Tx as per pyelonephritis.

• Women: Trimethoprim 150mg po nocte up to 6/12 as prophylaxis; review if still recurrent. Consider pre-intercourse stat doses. Consider self administer trimethoprim 300mg 3/7 regime, with instructions to seek help when not resolved in 2/7.
• Men: Consider prostatitis if symptoms include lower back / perineal pain, painful ejaculation. Ix DRE prostate.