Initial Antimicrobial Therapy for Severe Sepsis with No Obvious Source in Adults with Normal Renal Function
| Clinical Condition | Antimicrobial Regimens (Intravenous Therapy) |
|---|---|
| Immunocompetent adult | The many acceptable regimens include (1) piperacillin-tazobactam (3.375 g q4-6h); (2) imipenem-cilastatin (0.5 g q6h), ertapenem (1 g q24h), or meropenem (1 g q8h); or (3) cefepime (2 g q12h). If the pt is allergic to β-lactam agents, use ciprofloxacin (400 mg q12h) or levofloxacin (500-750 mg q12h) plus clindamycin (600 mg q8h). Vancomycin (15 mg/kg q12h) should be added to each of the above regimens. |
| Neutropenia (<500 neutrophils/µL) | Regimens include (1) imipenem-cilastatin (0.5 g q6h) or meropenem (1 g q8h) or cefepime (2 g q8h) or (2) piperacillin-tazobactam (3.375 g q4h) plus tobramycin (5-7 mg/kg q24h). Vancomycin (15 mg/kg q12h) should be added if the pt has an indwelling vascular catheter, has received quinolone prophylaxis, or has received intensive chemotherapy that produces mucosal damage; if staphylococci are suspected; if the institution has a high incidence of MRSA infections; or if there is a high prevalence of MRSA isolates in the community. Empirical antifungal therapy with an echinocandin (for caspofungin: a 70-mg loading dose, then 50 mg daily), voriconazole (6 mg/kg q12h for 2 doses, then 3 mg/kg q12h), or a lipid formulation of amphotericin B should be added if the pt is hypotensive, has been receiving broad-spectrum antibacterial drugs, or remains febrile 5 days after initiation of empirical antibacterial therapy. |
| Splenectomy | Cefotaxime (2 g q6-8h) or ceftriaxone (2 g q12h) should be used. If the local prevalence of cephalosporin-resistant pneumococci is high, add vancomycin. If the pt is allergic to β-lactam drugs, vancomycin (15 mg/kg q12h) plus either moxifloxacin (400 mg q24h) or levofloxacin (750 mg q24h) should be used. |
| IV drug user | Vancomycin (15 mg/kg q12h) is essential. |
| AIDS | Cefepime alone (2 g q8h) or piperacillin-tazobactam (3.375 g q4h) plus tobramycin (5-7 mg/kg q24h) should be used. If the pt is allergic to β-lactam drugs, ciprofloxacin (400 mg q12h) or levofloxacin (750 mg q12h) plus vancomycin (15 mg/kg q12h) plus tobramycin should be used. |
Abbreviation: MRSA, methicillin-resistant Staphylococcus aureus.
Source: Adapted in part from DN Gilbert et al: The Sanford Guide to Antimicrobial Therapy, 43rd ed, 2013, Antimicrobial Therapy, Inc., Sperryville, VA.