Infection
Home; Respiratory

Sepsis Guidelines 2008

  • GRADE system: {1|2}={strong|weak} recommendation with {A|..|D}={high|..|very low} qual of evidence
  • early goal-directed resuscitation during first 6hrs after recognition (1C)
  • blood cultures before antibiotic therapy (1C)
  • prompt imaging studies to confirm potential src of ifctn (1C)
  • admin of broad-spectrum antibiotic therapy <=1hr of Dx of septic shock (1B) and severe sepsis w/o septic shock (1D)
  • reassessment of abx tx with microbiology and clin data to narrow coverage, when appropriate (1C)
  • a usual 7-10 d of abx tx guided by clin response (1D)
  • src control with attention to the balance of risks and benefits of the chosen method (1C)
  • admin of either crystalloid or colloid fluid resus (1B)
  • fluid challenge to restore mean circulating filling pressure (1C)
  • reduction in rate of fluid admin with rising filling pressures and no improvem in tissue perfusion (1D)
  • vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure MAP>=65mmHg (1C)
  • dobutamine inotropic tx when CO remains low despite fluid resus and combined inotropic/vasopressor tx (1C)
  • stress-dose steroid tx given only in septic shock after BP is identified to be poorly responsive to fluid and vasopressor tx (2C)
  • recombinant activated protein C (rAPC) in pts with severe sepsis and clin assessm of hi risk for death (2B except 2C for postop pts)
  • In the absence of tissue hypoperfusion, CAD, or acute haemorrhage, target an Hb of 7-9g/dL (1B)
  • a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS)
  • application of at least a minimal amount of PEEP in ALI (1C)
  • head of bed elevation in mechanically ventilated pts unless contraindicated (1B)
  • avoiding routine use of pulmonary artery catheter in ALI/ARDS (1A)
  • to dcr days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for pts with established ALI/ARDS who are not in shock (1C)
  • protocols for weaning and sedation/analgesia (1B)
  • using either intermittent bolus sedation or continuous sedation with daily interruptions or lightening (1B)
  • avoidance of neuromuscular blockers, if at all possible (1B)
  • institution of glycaemic control (1B), targeting a BG<150mg/dL(<8.3mM/L) after initial stabilization (2C)
  • equivalency of continuous veno-veno haemofiltration or intermittent haemodialysis (2B)
  • DVT prophylaxis (1A)
  • use of stress ulcer prophylaxis to prevent upper GI bleeding using H2 blockers (1A) or PPI (1B)
  • consideration of limitation of support where appropriate (1D)
  • specific for paediatric severe sepsis: greater use of physical exam therapeutic endpoints (2C), dopamine as the first drug of choice for hypotension (2C), steroids only in children with suspected or proven adrenal insufficiency (2C), recommendation against use of rAPC (1B)

Antibiotic guidance (OHCM)

Bacterium Pen
V/G
Flu
clo
Amo
xic
Coa
mox
Taz
=PT
Cfo
tax
Cfu
rox
Cft
azi
Imi
Mer
Cla
ryt
Cli
nda
Dox
ycy
Tri
met
Gen
tam
Van
Tei
Met
ron
Cip
rof
Staph(PS) 1 2 2 2 . 2 2 . . 2- 2- 2- . 2 2 - .
Staph(PR)* - 1 - 2 2 2 2 . 2 2- 2* 2-* .* 2- 2* - .
Strept.A 1 . 2 2 2 2 . . 2 2- 2 - . - 2 - -
Strep.pne 1~ . 1 2 2 2 2 . 2 2- - 2- - - 2 - -
Enterococ - - 1 2 2 - - - 2 . - - . - 2 - -
N.meningi 1 . 2 . 2 2 2 . 2 . . - - - - - 2
Listeria . . 1 . 2 - - - 2 - - . . 2 . - .
H.influen - - 1- 2 2 2 1 . 2 - - 2- 2 . - - 2
E.coli - - 2- 2 2 2 2- - 2 - - - 1- 1~ - - 2
Klebsiell - - - 2 2 2 2- 2- 2 - - - 1- 1~ - - 2
Enterobac - - - 2- 2 2 2- 2- 2 - - - 1- 1~ - - 2
Proteus - - 1- 2 2 2 2- - 2 - - - 1- 1~ - - 2
Pseudomon - - - - 1 - - 1- 2 - - - - 1~ - - 1
Bact.frag - - - 2 2 - - - 2 - 2 . - - - 1 -
Bact(oth) 2 - - 2 2 - - - 2 - 2 . - - - 1 -
C diffici . . . . . . . . . . . . . . 2o 1 .
oral/iv oi oi oi oi i i oi i i oi oi o o i oi oi oi
Legend: -/~ =resistance likely/rare; .=usu inappropriate
*MRSA: ± Nitrofurantoin, ±Fusidate/Rifamp, Linezolid, Quinupristin/Dalfopristin, Tigecycline, Daptomycin

Pneumonia: see also Respiratory

Antibiotics (BNF)

Antibiotic oral iv Brand
Pen G=Benzylpen - 600[1200+]qds[-2400q4h] Crystapen®
Pen V=Phenoxym 500-1000qds - .
Amoxicillin 250[-500]tds 500tds[-1000qds-2000q4h] Amoxil®
Co-amoxiclav 375[-625]tds 1200tds[-qds] Augmentin®
Tazocin®
=Pip+Tazob
- [2250-]4500tds[-qds] .
Cefotaxime - 1000bd-2000qds Claforan®
Cefuroxime ~axetil:250[-500]bd 750[-1500]tds[-qds] Zinacef®(iv)
Ceftazidime - 1000tds/2000bd[-3000bd] Fortum®,Kefadim®
Imipenem+Cilastatin - 250qds/500tds[-1000qds] Primaxin®
Meropenem - 500[-1000-2000]tds Meronem®
Clarythromycin 250[-500]bd 500bd Klaricid®
Clindamycin 150-300[-450]qds 300bd-1200qds Dalacin C®(300iv)
Doxycyclin 100-200[-400]od - Vibramycin®
Trimethoprim 200bd - .
Gentamicin - 5-7/kg .
Vancomycin 125+qds [500-]1000bd Vancocin®
Teicoplanin - [200-]400od Targocid®
Metronidazol 400-500tds PR:1000tds[-bd]|500tds Flagyl®
Ciprofloxacin 250bd 200-400bd Ciproxin®
 

AIDS

1994 expanded WHO case definition: HIV AB +ve, and 1+ of:
  • >10% wt loss or cachexia, with diarrhoea and/or fever >1 mth (otherwise unexplained)
  • cryptococcal meningitis
  • [extra-/]pulmonary tuberculosis
  • Kaposi's sarcoma
  • neurological impairment sufficient to prevent independent daily activities (otherwise unexplained)
  • candidiasis of oesophagus (candidiasis of mouth and dysphagia)
  • life-threatening or recurrent pneumonia (with/without aetiological confirmation)
  • invasive cervical cancer