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Antimicrobial Stewardship (AMS)

Resources to help you ensure the safe and effective use of antimicrobials in NSHA patients.

Sepsis

  • Be aware that fever alone does not equate sepsis. Sepsis is a medical emergency. Most febrile illnesses are not medical emergencies and should be managed according to the clinical syndromes they fit, using available guidance.
  • Sepsis: Life threatening organ dysfunction due to dysregulated host response to infection.
  • Septic shock: Sepsis complicated by profound circulatory, cellular, and metabolic abnormalities and associated with a greater risk of mortality than with sepsis alone. 
    • Sepsis plus vasopressors and lactate > 2 mmol/L

Last reviewed January 2021

  • Assess for possible source of infection such as abscesses, intravascular lines, pacemakers, prosthetic heart valves, surgical sites, prosthetic joints, etc.
  • Make every effort to collect blood cultures (x 2 sets, at least 1 aerobic and anaerobic set, using 2 sites) before antibiotic initiation, but do not delay antibiotics if unable to obtain blood cultures.
    • The sensitivity of blood cultures is significantly lower if collected after antibiotic administration
  • Urine culture if urinary symptoms
  • Sputum culture if respiratory source suspected
  • Consider other specimens such as CSF for meningitis/encephalitis, nasopharyngeal swab for influenza, etc.
  • Imaging as indicated by presentation

Last reviewed January 2021

  • Consider recent antibiotic use (within 90 days) and previous colonization or infections with resistant microorganisms, (e.g.,  Pseudomonas or MRSA) that may change empiric management suggestions below.
  • MRSA risk factors: Injection drug use, recurrent abscesses, known MRSA colonization, previous MRSA infection
  • Source control as indicated

Last reviewed January 2021

  • Assess empiric antimicrobials daily, to determine if antibiotics can be
    • stopped,
    • narrowed based on microbiology, 
    • require adjustment to treat resistant microorganisms, or 
    • changed to oral regimen
Sepsis Origin Empiric Initial Intravenous Antibiotic
Unknown
  *Piperacillin/tazobactam 4.5 g IV 
ADD Vancomycin 25 mg/kg IV if MRSA risk factors
Lung (pneumonia)
Community Acquired Ceftriaxone 1 g IV and Azithromycin 500 mg IV
OR 
Levofloxacin 750 mg IV 
Hospital Acquired *Piperacillin/tazobactam 4.5 g IV
ADD Vancomycin 25 mg/kg IV if MRSA risk factors
Intra-abdominal
Community Acquired Ceftriaxone 1 g IV and Metronidazole 500 mg IV
Hospital Acquired *Piperacillin/tazobactam 3.375 g IV (if confirmed or suspected Pseudomonas use 4.5 g IV q6h)
Urological
Community Acquired Ceftriaxone 1 g IV
Hospital Acquired *Piperacillin/tazobactam 3.375 g IV (if confirmed or suspected Pseudomonas use 4.5 g IV q6h)
Rapidly progressing/necrotizing fasciitis skin infection
  *Piperacillin/tazobactam 3.375 g IV and Clindamycin 900 mg IV
ADD Vancomycin 25 mg/kg IV if MRSA risk factors
Central nervous system
Acute community acquired meningitis Dexamethasone 10 mg IV before 1st antibiotic
Ceftriaxone 2g IV and Vancomycin 25 mg/kg IV
ADD Ampicillin 2 g IV for Listeria coverage if age greater than 50 or risk factors (excessive alcohol consumption, pregnant, immunocompromised)
 
* Initiate meropenem 500 mg IV instead of piperacillin/tazobactam if history of anaphylaxis to any penicillin antibiotic (e.g.. penicillin, cloxacillin, etc.). 
Avoid meropenem if history of severe delayed skin reaction/organ dysfunction (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and system symptoms, etc.) to any beta-lactam antimicrobial. 
Refer to NSHA beta-lactam allergy document for more information.

Last reviewed January 2021

1. Singer M et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. https://jamanetwork.com/journals/jama/fullarticle/2492881

Last reviewed January 2021