Sepsis

Treatment Protocol for Sepsis

Modified from a Swedish local Treatment Protocol [Region Skåne] for Severe Sepsis. Note that deviations may exist in different countries, check your own hospital’s local program and best-before date. This protocol was updated 2017-01-17.

Background

Early identification and correct treatment of patients with severe sepsis (“Blood poisoning”) will reduce mortality. Severe sepsis can affect everyone, but infants and elderly are at increased risk, as well as people with chronic diseases or impaired immune systems. Safe prevalence data is missing in Sweden but probably affects 100-300 people per 100,000 inhabitants and years. Mortality has been very high in previous studies, severe sepsis 20% and septic shock 45%. Later studies show a mortality rate of around 15-20%. Severe sepsis is one of the conditions for an emergency situation which is associated with highest mortality. According to international and national recommendations, patients with severe sepsis should receive proper antibiotic treatment within one hour of arrival at the hospital. Research has shown that early treatment with antibiotics, intravenous fluid, oxygen and supportive therapy is vital in severe sepsis. Inadequate initial antibiotic therapy in severe sepsis with positive blood culture leads to a doubling of mortality. Delayed adequate antibiotic treatment at septic shock increases mortality by almost 8 percent per hour during the first 6 hours. The more organ systems fail and the higher the initial lactate level, the higher the mortality. This treatment protocol describes a sepsis drug for the emergency treatment of patients who have or suspected to be suffering from severe sepsis and septic shock. The goal of the sepsis chain is to identify patients with an infection at risk of developing severe sepsis early on. As part of the sepsis chain, we have prepared support for treatment prehospitally, at the emergency room and in the correct care area. The care chain is supported by cooperation between several different areas of health care and focuses on early identification and treatment without delay.

Sequential Organ Failure Assessment (SOFA) Score

Organ System
Score
01234
Respiration
paO2/FiO2, kPa ≥ 53,3 < 53,3 < 40 < 26,7 a < 13,3 a
Coagulation
Platelets, × 109/l ≥150 <150<100 <50<20
Liver
Bilirubin, μmol/l<2020–3233–101102–204>204
Circulation
Blood Pressure/CatecholaminesMean arterial pressure ≥70 mm HgMean arterial pressure <70 mm HgDopamine <5 b
or dobutamine (regardless of dose)
Dopamine 5,1–15 b
or epinephrine ≤0,1 b
or norepinephrine ≤0,1 
Dopamine >15 b or epinephrine>0,1 b
or noradrenalin >0,1 b
CNS
Glasgow Coma Scale or 1513–14 10–126–9<6
Reaction Level Scale1234–56–8
Renal Function
Creatinine, μmol/l and/or diuresis, ml/day<110110–170171–299300–440
<500
>440
<200
The original publication for SOFA also requires breathing support for 3 or 4 points [17]. The Swedish Intensive Care Register has chosen to abstain from this requirement, which we propose should apply as general Swedish practice.
FiO2 = fraction inspired oxygen; paO2 = partial pressure oxygen in arterial blood.
bUnits: μg/kg/min. Catecholamines should have been given for at least 1 hour.

Definition of Sepsis

Sepsis is defined as an infection that provides a systemic response in the form of:

  • Fever (> 38 °C) or low body temperature < 36 °C
  • Tachycardia > 90 beats/minute
  • Elevated respiratory rate > 20 breaths/minute
  • Leukocyte count > 12 x 109/L or < 4 x 109/L

New definitions, diagnostic criteria and codes for sepsis and septic shock according to Sepsis-3

 Sepsis Septic Chock
Definition Life-threatening organ dysfunction caused by systemic response to infectionA subset of sepsis where underlying circulatory and cellular / metabolic disorders are sufficiently pronounced to significantly increase mortality
Diagnostic CriteriaAcute change infection corresponding to at least 2 SOFA points 1Remaining hypotension requiring vasopressor to maintain mean arterial pressure ≥65 mm Hg with lactate> 2 mmol / l despite adequate fluid supply
Coding (ICD-10 SE)R65.1 Sepsis, Sepsis-3 organ failure (increase of at least 2 SOFA scores) Systemic Inflammatory Response Syndrome [SIRS] of Infectious Source with Organ Weight 2R57.2 Septic chock
1  If the 2-point increase is achieved by increment of 1 point in two organ systems, these changes should have taken place with sufficient simultaneousity: within 36 hours. SOFA = Sequential organ failure assessment.
2  Unfortunately, the old text so far will remain, as it is set by the WHO and is currently unchanged.

If two of the above factors meet the patient’s criteria for sepsis, however, what we in everyday terms call “sepsis or septic” is in fact, severe sepsis or septic shock, that is, the infection has led to hypotension, hypoperfusion and/or organ failure. The Swedish Infectious Disease Association has developed guidelines for assessing severe sepsis and septic shock as described below. The changes should be caused by a systemic reaction and not be a direct effect of local infection focus, the changes should be newcomers and not caused by other underlying disease. For the definition of severe sepsis to be met, the patient must have sepsis as described above and that one or more of the following criteria are present;

Hypotension

  • Systolic blood pressure < 90 mm Hg

Organ dysfunction

  • Changed mental status;
    • Confusion
    • Anxiety
    • Aggressiveness
    • Somnolence
  • Renal failure;
    • S-Creatinine increase > 45 μmol/L or
    • Oliguria, urinary output < 0.5 ml/kg for at least 2 hours despite adequate fluid supply
  • Respiratory insufficiency:
    • pO2 < 7.0 kPa on air (SaO2 approximately < 86%)
    • pO2 < 5.6 kPa on air (approximately < 78%) if the lung is the focus of the infection
  • Coagulopathy;
    • Petechiaes
    • Echymoses
    • INR > 1.5
    • APT time > 60 sec
    • TPC < 100
  • Liver affection;
    • s-Bilirubin > 45 μmol/L

Hypoperfusion

  • Lactate > 1 mmol above the upper reference value, all BE ≤ 5 mmol/L
  • Reduced capillary refill
  • Cold moist skin
  • Skin marmoration, discolorization

*Bowel problems (lack of bowel noise/gastrointestinal disorders such as abdominal pain, diarrhea or vomiting) are assessed as organ effects in international guidelines, but not in the Swedish Infectious Diseases Doctors’ guidelines.

The many times fast and hard-to-predict disease progression in severe sepsis emphasizes the importance of clear routines for monitoring vital parameters and set limits for doctor contact and intensive care. Especially during the first day after sepsis debut, patients are at risk of deterioration, which justifies increased monitoring and preparedness during this period to prevent development to;

  • Progressive severe sepsis: impairment of vital parameters or rising lactate during observation time.
  • Septic shock: sepsis with hypotension despite adequate fluid therapy.

Epidemiology

Severe sepsis can affect everyone, but infants and elderly are at increased risk, as well as people with chronic diseases or impaired immune systems. Safe prevalence data is missing in Sweden but sepsis probably affects 100-300 people per 100,000 per inhabitant and year.

Preventive Measures

Appropriate treatment of antibiotic-requiring infections without unnecessary delay is important to prevent the development of severe sepsis. Work with National Guidelines for antibiotic therapy (In Sweden called “STRAMA – Guidelines“) is a good application for physicians to provide antibiotics with the correct indication. An overly wide range of antibiotics may risk creating conditions for the development of antibiotic resistance, which in turn may adversely affect the result of severe sepsis. For more information about STRAMA’s Outpatient Guidelines – here is a link.

General vaccination programs are essential for preventing the development of certain serious infectious diseases. Annual influenza vaccination of risk groups may be particularly noted as an important measure for preventing secondary sepsis cases, as well as pneumococcal vaccination according to given recommendations. Immune-suppressed patients constitute a particularly exposed group and it is therefore of great importance that these patients in infectious complications meet physicians with the appropriate skills to assess the sometimes diffuse symptoms that may occur or indicate a serious infection. It is also important to inform patients with immuno suppressive treatment how to act at signs of infection. Occasionally, special vaccination may be indicated in immuno suppression.

Symptoms, Clinical Findings and Early Identification

Severe sepsis is a serious infection that is characterized by organ damage. Most patients with acquired severe sepsis and septic shock are classified as red or orange alarms according to the Rapid Emergency Triage and Treatment System (RETTS) already on arrival at the emergency ward. However, the initial clinical picture may be difficult to interpret and a range of symptoms and clinical findings may occur which may vary depending on the source of the infection, infectious agent and patient age and comorbidity.

Patients with severe sepsis or septic shock often have fever or a history of fever and one of the following; tachycardia > 90/min, increased respiratory rate > 20/min, drop in blood pressure, low oxygen saturation < 90 %, anxiety and confusion, gastrointestinal symptoms such as abdominal pain, diarrhea or vomiting. With typical symptoms and an acute illness with chills, high fever and affected general condition, it is easy to suspect severe sepsis, but many patients, especially elderly people, often exhibit a more atypical picture with confusion as the only presenting symptom of severe sepsis. It is important to always have sepsis in mind when investigating a severely ill patient with an unclear diagnosis.

Please note the following symptoms of a severe infection:

C-BRS – Consciousness/Blood Pressure/Respiratory Rate/Oxygen Saturation, or the 90/30/90 rule:

  • Consciousness; reduced/impaired mental status
  • Systolic blood pressure < 90 mm Hg
  • Respiratory rate > 30 breaths per minute
  • Saturation < 90%

Sepsis Alarm

To allow early identification, a sepsis alarm should be used, which means a modified version of RETTS for focus on patients at risk of serious infection. Rapid Emergency Triage and Treatment System (RETTS) is the sorting system used for many emergency services around the world. RETTS is based on registration of vital parameters (blood pressure, heart rate, respiratory rate, vomiting and temperature) with specified limits to sort patients to the correct priority group.

Red Alarm by RETTS means that the patient’s oxygenation is below 90% despite oxygen treatment, the respiratory rate is over 30 or below 8, blood pressure < 90 mm Hg, pulse rate > 130 or the patient develop convulsions or is unconscious.

To vital parameters, a so-called “ESS” (Emergency Signs and Symptoms) is added. In severe sepsis, ESS 47 may be added (infection, fever, local infection). ESS 51 should also be added (known as adrenal, corticosteroid, immunodeficiency or immunosuppression) which ultimately determines the patient’s priority.

Sepsis alarm is called out in patients with red RETTS who have fever or a medical history of fever. In these cases, the patient is triaged according to a special algorithm and the physician/emergency doctor is called to the emergency room immediately when the patient arrives.

By early focus on patients who have established sepsis or is at risk of severe sepsis, it is ensured that the patient receives adequate antibiotics within 60 minutes after sampling of blood cultures (2 + 2) and proper supportive treatment is initiated and continued with i.v. fluid and oxygen.

CHECK POINTS TO BE CONSIDERED TO RECOGNIZE PATIENTS WITH SEVERE SEPSIS

  • Fever (> 38.0 °C) does not always occur and ear thermometers are unreliable. Low body temperature (< 36.0 °C) can be a serious sign of severe sepsis
  • “Patient found on the floor” may be secondary to sepsis
  • Sepsis-triggered confusion can be misinterpreted as stroke
  • Keep in mind that gastrointestinal symptoms and flu-like conditions may be due to severe sepsis
  • CRP can be normal or only moderately elevated initially
  • Note colour of the skin – subcutaneous bleedings? Infected wounds? Petechial spots?
  • Observe reduced immune responses in certain groups, e g patients with rheumatic systemic diseases, IBD, malignant tumor diseases, transplanted patients, splenectomized patients, and patients with ongoing or recent treatment with immunomodulatory drugs (such as corticosteroids, Prednisolon® 15 mg or more, Metothrexate®, Remicade® (Infliximab) or Enbrel® (Etanercept))

Primary Target

  • Adequate monitoring – follow blood pressure, pulse, oxygen saturation, consciousness!
  • Establish peripheral vascular access (x 2)
  • Oxygen 2-5 liters by nasal cannula, > 5 liters by mask, oxygen saturation > 93 %. Caution in COPD! Inform the emergency ward if the patient has COPD.
  • Infusion of crystalloid solutions; Ringer’s Acetate, if SBP < 90 mm Hg, a bolus dose is administered of 500-1 000 ml for 30 minutes, repeat to treatment target, i.e. SBP > 90 mm Hg. In total, at least 30 ml/kg of crystallloids i.v. should be given within 3 hours of severe sepsis with hypotension.
  • Paracetamol is given only when the patient is clinically affected by fever or in ongoing cerebral ischemia/convulsions/cardiac ischemia.

 Prehospital Identification and Treatment

  • Suspicious infection is generally identified using the RETTS classification
  • ESS 47 is added to vital parameters, which determines the patient’s priority.
  • In some cases, ESS 51 (known adrenal corticosteroid deficiency, immuno deficiency or immuno suppression) should also be used.
  • In addition to this analysis, one should also note the following criteria that are indicative of suspected severe infection;
  • Fever (temp > 38.0 °C) or low temp (< 36.0 °C) and any of the following symptoms/signs:
    • Petechiaes/rash
    • Signs of infected skin/soft parts/joints
    • New severe pain
    • Cerebral affection/severe headache
    • Urinary tract symptoms (especially in patients with urinary catheter)
    • CVC or other vascular port with signs of infection

Epidemiology? Always ask the patients if they have been traveling abroad lately

Keep in mind that fever may be absent in immunosuppressed patients and in patients taking paracetamol and NSAID:s, and diarrhea/abdominal pain/vomiting are common symptoms in severe sepsis.

  • Oxygen 2-5 liters by nasal cannula or > 5 liters by mask, to reach an oxygen saturation > 93 %. Caution in COPD! Inform the emergency ward if the patient has COPD.
  • Establish peripheral vascular access (x 2)
  • Consider an intraosseos vascular access when difficulties with PVC in critically ill patients who are immediately in need of fluid/drug administration.
  • Infusion of crystalloids such as Ringer’s solution. If SBP < 90 mm Hg give a bolus dose of 500-1 000 ml for 30 min, repeat to achieve treatment goal, i.e. SBP > 90 mm Hg. In total, at least 30 ml/kg i.v. should be given within 3 hours in case of severe sepsis with hypotension.
  • Disallow general paracetamol ordination when the indication is fever. Pharmacological reduction of fever is given only when the patient is clinically affected by the fever or in ongoing cerebral ischemia/convulsion/cardiac ischemia.

In Hospital Diagnostics and Treatment

Primary Clinical Investigation

  • Initial emergency care according to A – B – C – D – E
  • Peripheral vascular access (PVC x 2)
  • Consider a central venous line or intraosseous access if difficulty of PVC in critically ill patients who are immediately in need of access to fluid/drug administration.
  • Blood culture (2 + 2)
  • Blood gas sampling, arterial or venous for the analysis of lactate
  • Blood samples; CRP, leukocytes, thrombocytes, PK/INR, APT time, liver transaminases, urinary-stick, B-glucose.
  • Urine cultivation (if necessary by urinary catheter) and other relevant cultures after prescription.
  • Is there a suspected bacterial infection? Determine infectious focus. After adequate cultivation, determine relevant choice of antibiotics
  • If meningitis is suspected consider lumbal puncture, see National Guidelines [In Sweden: www.infektion.net]
  • ECG
  • Consider x-ray thorax/pulmonary bedside and other radiological examinations
  • Check vital parameters every 5 minutes initially until the patient is stabilized
  • Epidemiology? Always ask the patient if they have been traveling abroad
  • Keep in mind that fever may be lacking in immunosuppressed patients and in patients taking paracetamol and NSAIDs, and diarrhea/abdominal pain/vomiting are common symptoms in severe sepsis.

Treatment

  • Infectious Disease Consultants/Emergency Medicine Physicians should be present in the emergency department during a sepsis alert. If infectious disease specialists are not available in the hospital, they should be contacted by telephone for advice on primary care and choice of antibiotics, especially in immunosuppressed patients and those patients who may carry resistant bacteria.
  • Give oxygen 2-5 liters by nasal cannula, or > 5 liters by mask to reach an oxygen saturation > 93 %. Caution in patients with COPD! Inform the emergency ward if the patient has COPD.
  • Infusion of crystalloids such as Ringer’s acetate. If SBP < 90 mm Hg give a bolus dose of 500-1 000 ml for 30 min, repeat to target SBP > 90 mm Hg. In total, at least 30 ml/kg i.v. should be given within 3 hours in case of severe sepsis with hypotension or lactate > 4
  • Choice of antibiotics is based on the severity of the infection and possibly, suspicious focus.

 

If antibiotics are prescribed, they should be given without delay at the emergency department!

  • Consider invasive treatment of infection focus (e.g. Source Control) at e.g. septic arthritis, abscess, pyelitis, empyema, intestinal perforation, gynecological infection or necrotizing fasciitis. Consult relevant surgeon.
  • If the patient is on or recently discontinued treatment with cortisone, give Solu-Cortef 100 mg i.v.
  • Urinary catheter with urinary output, target level 0.5 ml/kg/h.
  • Give Albumin 20% 100 ml for continued hypotension after 2-3 liters of crystalloids (Ringer Acetate), do not use starch preparations (e g Voluven, HAES), if Albumin is not available, continue with Ringer Acetate.
  • Refrain from generalized paracetamol prescription in presence of fever. Paracetamol is given only when the patient is clinically affected by the fever or in ongoing cerebral ischemia/convulsion/cardiac ischemia. Paracetamol should be avoided in cases of liver affection.

* Which specialists who are consulted is adapted to the respective hospitals capacity; in hospitals where infectious disease specialists are available, these should be consulted, otherwise medical or emergency medical services according to local guidelines.

Level of Care – Admission of Patient

  • Decision on appropriate level of care; Intensive Care Unit/Intermediary Care or regular ward.
  • Consider need for isolation in case of resistant strains (ESBL, MRSA)
  • Transfer to an infectious disease ward, emergency ward or other ward with sufficient monitoring resources without delay, during waiting time to ward, vital parameters must be checked every 15 minutes.
  • Evaluate if there are evidence for treatment limitations

Emergency Ward – Progressive Decline of Vital Parameters after Initial Action

Establish contact with MIG-teams or ICU physician (or Infectious Consultant) for immediate referral to ICU care:

  • If SBP < 90 mm Hg despite i.v. fluid or
  • Oxygen saturation <90 despite oxygen
  • If lactate > 4 or ascending
  • If RR > 30 despite treatment
  • In case of serious organ failure, such as consciousness reduction

Clinical Investigation

  • Peripheral vascular access (x 2)
  • Consider a central venous line or intraosseous access if difficulty of PVC in critically ill patients who are immediately in need of access to fluid/drug administration.
  • Blood cultures (2 + 2)
  • Blood gas analysis, arterial or venous for the analysis of lactate
  • Relevant blood samples; CRP, leukocytes, thrombocytes, PK/INR, APT time, liver status, u-screen check, B-glucose.
  • Urine cultivation (if necessary by urinary catheter) and other relevant cultures after ordination.
  • Is there a suspected bacterial infection? Determine infection origen. After adequate cultivation, determine relevant choice of antibiotics
  • If meningitis is suspected consider lumbal puncture, see National Guidelines [In Sweden: www.infektion.net]
  • ECG
  • Consider radiological examinations such as x-ray thorax/lungs bedside
  • Check vital parameters every 5 minutes initially until the patient is stabilized.
  • Epidemiology? Always ask the patient if they have been traveling abroad
  • Keep in mind that fever may be lacking in immunosuppressed patients and in patients taking paracetamol and NSAIDs, and diarrhea/abdominal pain/vomiting are common symptoms in severe sepsis.

Treatment

  • Daytime preferentially treatment by infectious disease specialist*, on-call consultation or by telephone, assess the patient in the emergency ward, especially in immunosuppressed patients and in patients with known support of resistant bacteria.
  • Give oxygen, targeted by oxygen saturation, 1-5 liters on nasal cannula, or > 5 liters by mask, treatment aims at oxygen saturation > 93%. Caution in COPD!
    Infusion of crystalloid solutions (Ringer Acetate) 1 000 ml, in total, at least 30 ml/kg i.v. given within 3 hours of severe sepsis with hypotension or lactate > 4
  • Choice of antibiotics is based on the severity of the infection and possibly, suspicious focus.

If antibiotics are prescribed, they should be given without delay at the emergency department!

  • Consider invasive action of infection focus (e g source control) at e.g. septic arthritis, abscess, pyelitis, empyema, intestinal perforation, gynecological infection or necrotizing fasciitis.
  • If the patient is on or recently discontinued treatment with cortisone, give Solucortef 100 mg i.v.
  • Antipyretic agents is given only when the patient is clinically affected by fever or in an ongoing cerebral ischemia/convulsion/cardiac ischemia. Refrain from general ordination of paracetamol when the indication is fever.

* Which specialists who are consulted should be adapted to each hospitals capacity; in hospitals where infectious disease specialists are available, these should be consulted, otherwise medical or emergency medical services according to local guidelines.


Antibiotic Choice in Severe Sepsis

Choice of Antibiotics in Society Acquired Severe Sepsis and Septic Shock

Severe sepsis and septic shock are very serious conditions requiring early correct treatment. It is important to start with an effective antibiotic treatment.

Check if the presence of previous bearings of resistant bacteria exists and go through the microbiology domain, also evaluate local resistance conditions.

Connection with recommended antibiotic protocols should be established in the treatment of patients with progressive severe sepsis and septic shock, especially in suspect susceptibility to resistant bacteria or in immunosuppressed patients. The following antibiotic dosing protocols refers to the initial treatment, continued dosage and antibiotic treatment in case of persistent severe sepsis or septic shock should be discussed with the infection consultant.

The following antibiotic effects apply only in case of severe sepsis and septic shock, for correct treatment see previous definitions. Seek directed treatment if suspected infectious focus is present. In general, higher initial antibiotic doses and at denser intervals (an additional dose after 4 hours, the next dose 4 hours thereafter, in the treatment of severe sepsis/septic treatment with beta-lactam antibiotics such as Phenoxymethylpenicilline PCV, Cefotaxime, Piperacilline/Tazobactam and Meropenem/Imipenem) shock when the volume of distribution in these conditions is increased and causes low tissue concentrations during normal dosing. In stabilized conditions, normal dosage is used. For detailed information, see the national healthcare program www.infektion.net

ANTIBIOTIC CHOICE IN PATIENTS WITH SEVERE SEPSIS OR SEPTIC CHOCK

Source of InfectionAntibiotic Choice
Suspected pneumoniaCefotaxime 2 g + Tavanic 0,5 g
Suspected Urosepsis**Cefotaxime 2 g + Amino Glycoside* 4,5-7 mg/kg
Suspected Abdominal Foci**Piperacilline/Tazobactam 4 g/Meropenem 1 g/Imipenem 1 g + ev. Single Dose of Amino Glycoside* 4,5–7 mg/kg
Suspected skin/Soft tissue infectionSuspected Streptococcal genesis: Phenoxymethylpenicilline-pcV 3 g + Clindamycine 600 mg
Suspected Staf. Aureus genesis Cloxacilline 2 g + Clindamycine 600 mg
Suspected Fasciitis/Myositis Meropenem/Imipenem 1 g + Clindamycine 600 mg + ev. Amino Glycoside* 4,5–7 mg/kg
Suspected meningitisCefotaxime 3 g + Ampicilline 3 g + Betametason
Unknown Foci**Piperacilline/Tazobactam 4 g/Meropenem 1 g/Imipenem 1 g + Amino Glycoside* 4,5–7 mg/kg.
In a stable patient with rapid transient organ failure, treatment with Cefotaxime 2 g + Amino Glycoside* 4.5 mg/kg may be considered.
Unknown foci and Type 1 hypersensitivity to Penicilline

 
Clindamycine 600 mg + Ciprofloxacin 400 mg + Hypersensitivity to penicillin: a dose Amino Glycoside* 4,5–7 mg/kg
* Give the higher dose of aminoglycoside in progressive severe sepsis and septic shock. In the case of mild severe sepsis that responded well to initial fluid therapy, aminoglycoside can be waived.

** If current or previous carrier of ESBL-producing pathogen, Meropenem/Imipenem 1 g should be given initially. If the risk factors for infection caused by ESBL-producing pathogens such as a foreign residence in a region with high incidence of antibiotic resistance or stay in a shelter with high incidence of resistant bacteria, contact the infection consultant.

CHOICE OF ANTIBIOTICS IN THE CASE OF A PREGNANT PATIENT WITH SEVERE SEPSIS OR SEPTIC CHOCK

Penicillines, cephalosporines, carbapenemes, clindamycine are all good to give. A dose of aminoglycoside may be considered if the indication is strong, consult an infectious disease physician. Avoid quinolones throughout pregnancy, avoid macrolides during the first trimester (doxycycline may be given first trimester, but avoid second and third trimester), for more information see also www.infpreg.se.

CHOICE OF ANTIBIOTICS IN THE CASE OF PATIENTS WITH BOTH ACUTE RENAL FAILURE AND SEVERE SEPSIS OR SEPTIC CHOCK

Acute renal failure is common in severe sepsis and septic shock. Basically, the first dose can always be given as full dose, but after that, doses may be adjusted after renal function.

Antibiotics in Case of Impaired Renal Function
Creatinine Clearance (ml/min)> 80 ml/min80-41 ml/min40-20 ml/min< 20 ml/min
Ampicillin2 g x 32 g x 32 g x 21 g x 2
Phenoxymethylpenicilline 1 g x 31 g x 31 g x 21 g x 2
Cloxacillin2 g x 32 g x 31 g x 31 g x 3
Piperacillin + tazobactam4 g x 34 g x 34 g x 34 g x 2
Cefotaxime1 g x 31 g x 31 g x 21 g x 2
Ceftazidime at neutropenia1 g x 3

1 g x 4
1 g x 2

1 g x 3
0,5 g x 2

0,5 g x 3
0,5 g x 1

0,5 g x 2
Meropenem at neutropenia0,5 g x 3

0,5 g x 4
0,5 g x 3

0,5 g x 4
0,5 g x 2

0,5 g x 3
0,25 g x 2

0,5 g x 2
Ciprofloxacin400 mg x 2400 mg x 2400 mg x 1400 mg x 1
Tobramycin*6-4,5 mg/kg x 14,5-2,2 mg/kg x 12,2-1 mg/kg x1 

CHOICE OF ANTIBIOTICS IN THE CASE OF HEAVILY OVERWEIGHT/OBESE PATIENTS WITH SEVERE SEPSIS OR SEPTIC CHOCK

There is uncertainty about optimal antibiotic doses in severe overweight/obesity. In the meantime, Swedish Infectious Disease Association recommends adjustment for certain antibiotics at BMI > 30 kg/m2 (BMI = weight/length2). Contact the Infectious Disease Consultant for advice.

CHOICE OF ANTIBIOTICS IN THE CASE OF PATIENTS WITH SEPSIS WITHOUT ORGAN DYSFUNCTION (FEBRILE, BACTERIAL INFECTION)

Source of InfectionAntibiotic Choice
With unknown origenPhenoxymethylpenicillin 1-3 g + Amino Glycoside 4.5 mg/kg alternatively Cefotaxime 1 g if risk factors for Amino Glycoside related side effects are known as known hearing loss or chronic renal impairment.
With suspected focus; for example pneumonia, febrile UVI / pyelonephritis, erysipelas.Antibiotic treatment in accordance with local guidelines or STRAMA Guidelines for infections in hospitalized patients.

Other Treatment Aspects in Case of Severe Sepsis

  • Thrombosis prophylaxis: Low molecular weight heparin (LMWH) and supportive stockings should be given to all patients with severe sepsis, refrain if substantially increased bleeding risk or other contraindication is present.
  • PPI – If PK/INR is > 1.5 or TPC < 50 or hypotension is present give PPI (proton pump inhibitor) as ulcer prophylaxis, fro example Nexium 40 mg x 1 iv. The treatment is discontinued when the patient is stabilized and may take nutrients orally.
  • B-glucose control: Aim at B-glucose values ​​<10 mmol/l

Ethical Considerations in the Case of Severe Sepsis

This treatment protocol is a support for initial treatment, it is important that ethical principles, possible underlying chronic disease forecasts and acute disease forecasts be included in the assessment and that each patient is evaluated individually for appropriate care efforts and health care. Treatment paths shall be motivated and recorded.

In the group of multi-sick and aged elderly patients, after the patient’s opinion, it occurs that the patient does not wish for emergency medical care. In these cases, home care can be provided with support from mobile elderly teams whenever possible. If this care is not available, you can adjust the care in the best way according to the given conditions.

Follow-Up

Proper pending monitoring and evaluation of treatment effect through control of lactate levels and vital parameters according to the patient’s RETTS.

A reasonable treatment goal is that within one hour of treatment start, the patient has systolic blood pressure > 90 mm Hg and oxygen saturation > 93% (not applicable to COPD). Within 6 hours urinary production should be adequate (> 0.5 ml/kg/h) and a possible elevated lactate should have fallen. After 3-6 hours, the responsible physician should evaluate whether the patient has achieved the set treatment goals. The risk of rapid deterioration is highest during the first 24 hours in hospital. If failing vital parameters, NEWS > 6 establish contact with MIG and telephone contact with infection consultant*

Before leaving the emergency department, NEWS will be performed and upon arrival at the department, NEWS will be performed again. Reporting to the department should report clear levels of continued fluid treatment, continued oxygen treatment, saturation and blood pressure levels, and when the next antibiotic dose is to be given and at what dose, and intervals for NEWS assessment.

* Which journeys are summoned may be adapted to the respective hospitals; in the hospital infectious care available, this should be called/requested, otherwise medical or emergency medical services, etc. local guidelines.

Registration of Diagnosis

It is of the utmost importance that emergency services have procedures that ensure that sepsis alarms are properly registered, (ICD-10) so that proper evaluation is feasible. For this purpose, the appropriate person should be appointed e.g. in the secretary group at the emergency ward. Improved diagnosis of patients with severe sepsis and septic shock at the time of printing is necessary, see below.

  1. Severe sepsis and septic shock are coded with organ problems such as pneumonia, erysipelas, renal pelvic inflammation as a major diagnosis. If the focus is unclear, the diagnostic codes A40 – A41 will be used.
  2. To identify severe sepsis, the underlying codes R65.1 (Severe Sepsis) and R57.2 (Septic Shock) are mandatory.
  3. Organ failure and multiple organ failure are coded for each failure organ (acute respiratory failure J96.0, ARDS J80.0, acute renal failure N17.8, hypotension I95.8, coagulation disorder D68.9, DIC D65.9, liver failure K75.8, encephalopathy G93. 4).

References and links

  1. Surviving Sepsis Campaign, via the link http://www.survivingsepsis.org
  2. Infectious Disease Care Program, version 2013 via the link www.infektion.net
  3. Glickman et al 2010, Acad Emerg Med. 2010 Apr; 17 (4): 383-90. doi: 10.1111/j.1553-2712.2010.00664
  4. Widgren B et al. The Journal of Emergency Medicine, 2011; 40: 623-628.