Review of Surviving Sepsis Guidelines: Initial Antibiotic / Antimicrobial Therapy

Sep 02, 2013

Initial Antibiotic / Antimicrobial Therapy in Severe Sepsis/Septic Shock

For Sepsis, Use the Right Antibiotics at the Right Time (= As Early As Possible)

See all the Surviving Sepsis Guidelines

PulmCCM is not affiliated with the Surviving Sepsis Guidelines or the Surviving Sepsis Campaign which is at http://www.survivingsepsis.org.

The short version: Give appropriate and effective antibiotics as early as possible for patients known or suspected to be in severe sepsis or septic shock.

Give antimicrobials likely to be effective against the pathogens causing septic shock intravenously within the first hour after severe sepsis or septic shock is recognized.
Antimicrobials should be chosen that cover all the likely causative pathogens -- nearly always including bacteria, but sometimes also fungi and/or viruses.
Antimicrobials should be selected that are expected to penetrate into the presumed infected tissues.

Antibiotics must be selected according to the patient's unique clinical picture (symptoms, signs, indwelling devices, neutropenia, gut integrity, etc.), and also guided by local patterns of infection and resistance (e.g., high community rates of MRSA; high hospital rates of fluoroquinolone-resistant Pseudomonas, etc.) This complex process cannot be protocolized and depends on good physician skills and judgment. Strength: Grade 1B (strong recommendation with moderate-quality evidence).

De-escalate Antibiotic Therapy for Sepsis Whenever Possible

After appropriately broad antibiotic therapy has begun for patients with severe sepsis or septic shock, consideration should be given throughout the patient's clinical course to reducing antibiotic therapy to the minimum drugs and doses necessary:

Review the antibiotic / antimicrobial regimen daily, and de-escalate therapy (eliminate unnecessary antbiotics; change to narrow-spectrum antibiotics) whenever appropriate. Strength: Grade 1B (strong recommendation with moderate-quality evidence).
Consider using procalcitonin to help gain confidence in stopping empiric antibiotics in patients who appeared to have severe sepsis or septic shock at first, but now have a lower suspicion for infection. Low procalcitonin levels reduce the likelihood of bacterial infection, albeit imperfectly. Strength: Grade 2C (weak recommendation with low-quality evidence).

When to Use Combination Antibiotic Therapy for Severe Sepsis/Septic Shock

Use combination therapy (multiple drugs active against the same organisms, through different mechanisms of action) when appropriate, but for only a limited time (3-5 days). Combination therapy is recommended by the Surviving Sepsis Campaign for patients with septic shock or severe sepsis and:

Neutropenia
Multi-drug resistant bacteria like Pseudomonas, Acinetobacter, et al
Pseudomonas aeruginosa bacteremia causing septic shock and respiratory failure; use an extended-spectrum beta-lactam and either a fluoroquinolone or aminoglycoside.
Streptococcus pneumoniae with bacteremia and septic shock; combine a beta-lactam and a macrolide.

There may be other situations when combination therapy including is appropriate using carbapenems, colistin, rifampin, or other drugs (e.g., settings in which highly resistant organisms are prevalent); evidence is largely absent to guide these decisions and no guidelines can advise on all such clinical situations. When using combination therapy empirically (without positive culture data or a clear site of infection), limit use to 3-5 days, then eliminate one or more of the antimicrobials being used. If positive cultures and sensitivity data are available sooner than 3-5 days, narrow antibiotic use as soon as data are available. Strength: Grade 2B (weak recommendation with moderate-quality evidence).

How Long to Treat Severe Sepsis/Septic Shock With Antibiotics?

Treat most infections in people with severe sepsis / septic shock for 7-10 days total. Longer treatment might be appropriate for patients who:

Are responding slowly;
Have abscesses, empyema, or other infectious foci which are not amenable to drainage;
Have Staphylococcus aureus bacteremia;
Have unusual infections (e.g., fungal or viral);
Have immune deficiencies (e.g., neutropenia).

Strength: Grade 2C (weak recommendation with low-quality evidence).

Antibiotic Treatment in Severe Sepsis/Septic Shock: Other Points

Initiate antiviral therapy in the unusual patients with severe sepsis or septic shock caused by viral infections. Strength: Grade 2C (weak recommendation with low-quality evidence). Do not use antibiotics or other antimicrobial drugs in people with non-infectious severe inflammatory states (recommendation not graded). Guide to Recommendations’ Strengths and Supporting Evidence in the Surviving Sepsis Guidelines:

1 = strong recommendation;
2 = weak recommendation or suggestion;
A = good evidence from randomized trials;
B = moderate strength evidence from small randomized trial(s) or upgraded observational trials;
C = low strength evidence, well-done observational trials with control randomized controlled trials
D = very low strength evidence, downgraded controlled studies or expert opinion.