Initial Antimicrobial Therapy for Severe Sepsis with No Obvious Source in Adults with Normal Renal Function | |
| CLINICAL CONDITION | ANTIMICROBIAL REGIMENSa |
|---|---|
| Septic shock (immunocompetent adult) | The many acceptable regimens include (1) piperacillin-tazobactam (3.375-4.5 g q6h), (2) cefepime (2 g q12h), or (3) meropenem (1 g q8h) or imipenem-cilastatin (0.5 g q6h). If the pt is allergic to β-lactam antibiotics, use (1) aztreonam (2 g q8h) or (2) ciprofloxacin (400 mg q12h) or levofloxacin (750 mg q24h). Add vancomycin (loading dose of 25-30 mg/kg, then 15-20 mg/kg q8-12h) to each of the above regimens. |
| Neutropenia (<500 neutrophils/µL) | Regimens include (1) cefepime (2 g q8h), (2) meropenem (1 g q8h) or imipenem-cilastatin (0.5 g q6h) or doripenem (500 mg q8h), or (3) piperacillin-tazobactam (3.375 g q4h). Add vancomycin (as above) if the pt has a suspected central line-associated bloodstream infection, severe mucositis, skin/soft tissue infection, or hypotension. Add tobramycin (5-7 mg/kg q24h) plus vancomycin (as above) plus caspofungin (one dose of 70 mg, then 50 mg q24h) if the pt has severe sepsis/septic shock. |
| Splenectomy | Use ceftriaxone (2 g q24h, or-in meningitis-2 g q12h). If the local prevalence of cephalosporin-resistant pneumococci is high, add vancomycin (as above). If the pt is allergic to β-lactam antibiotics, use levofloxacin (750 mg q24h) or moxifloxacin (400 mg q24h) plus vancomycin (as above). |
a All agents are administered by the intravenous route.
Source: Adapted in part from DN Gilbert et al: The Sanford Guide to Antimicrobial Therapy, 47th ed, 2017; and from RS Munford: Sepsis and septic shock, in DL Kasper et al (eds). Harrison's Principles of Internal Medicine, 19th ed. New York, McGraw-Hill, 2015, p. 1757.