ANTIBIOTICS IN SEPSIS

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1 ANTIBIOTICS IN SEPSIS Jennifer Curello, PharmD, BCPS Clinical Pharmacist, Infectious Diseases Antimicrobial Stewardship Program Ronald Reagan UCLA Medical Center October 27, 2014 The power of antibiotics December year old female presents with cellulitis and facial swelling after trauma Rapidly spreading Fever to 104 F Swelling dysphagia Gasping for breath No other significant PMH Patient was prescribed penicillin Prior to penicillin this little girl would have died in a matter of days. PMH: past medical history Herrell 43 Proc Staff Meetings Mayo Clinic 18:65-76 The power of antibiotics After 14 days of penicillin 65 years later Herrell 43 Proc Staff Meetings Mayo Clinic 18:

2 Why are antibiotics important in sepsis? Sepsis: Infection + 2 SIRS criteria Bacteria are the most common pathogens Increasing number of fungal pathogens Immunocompromised hosts Central venous catheters, Renal replacement therapy Prolonged exposure to broad-spectrum antibiotics Parenteral nutrition 2012 Surviving Sepsis Campaign recommendations for antibiotics: Administration of intravenous (IV) antibiotics within 1 hour of recognition of sepsis Anti-infective therapy should contain 1 agent(s) active against all potential pathogens and achieve adequate drug levels at suspected site of infection Regimen should be reassessed daily for possible de escalation Martin GS et al. N Engl J Med 2003; 348: Dellinger et al. Intensive Care Med (2013) 39: Time to first antibiotic dose matters! Kumar A, et al. Crit Care Med. 2006;34: The sepsis bundle 2

3 What are broad-spectrum antibiotics? Narrow Spectrum Broad Spectrum What will the doctors order in sepsis? Antibiotics considered broad-spectrum: Aztreonam Azithromycin Ceftriaxone Cefepime Piperacillin/tazobactam (Zosyn) Meropenem, Imipenem Ertapenem Ciprofloxacin, levofloxacin Gentamicin, tobramycin, amikacin Vancomycin First dose is usually a full dose regardless of renal/liver function! Blood cultures before antibiotics! Obtain blood cultures Antibiotics ordered Culture results return from microbiology Sepsis identified Antibiotics administered Antibiotics adjusted to target bacteria isolated in blood cultures 1 Hour Hours 3

4 Why is it important to target therapy? How are antibiotics selected? Route of administration: IV vs. PO IV is preferred in order to rapidly achieve adequate drug levels at the suspected site of infection Spectrum of activity Want to cover for as many pathogens as possible initially Will de-escalate coverage when culture results return What if my patient was already on antibiotics before they became septic? Current antibiotic is probably not treating bacteria causing new onset sepsis Antibiotic should be changed to one that is active against bacteria not being covered by the current antibiotic Antibiotic delivery at UCLA 60 minutes MD identifies sepsis & places order for antibiotics Pharmacy received order & dispenses antibiotics STAT Antibiotics are tubed to the nurse who administers the antibiotics to the patient 4

5 Timing of antibiotics In what order should antibiotics be given if line access is limited? All broad-spectrum antibiotics that can be given over 30 minutes should be administered FIRST 60 minutes Piperacillin/tazobactam Ceftriaxone Cefepime Meropenem, imipenem, ertapenem Ciprofloxacin, levofloxacin Gentamicin Azithromycin Vancomycin (given over 1+ hours) WHAT CAN I DO TO ENSURE ANTIBIOTICS ARE GIVEN STAT? Registered nurse (RN)-driven protocol Standardized, physician-approved assessment: RN screening of adult inpatients (plus emergency department) for sepsis, severe sepsis & septic shock Use the sepsis screening tool in CareConnect RN may implement sepsis treatment bundle elements in patients screening positive for severe sepsis and septic shock Labs - lactate Blood cultures 2 sets RN to notify physician of positive screen to initiate ordering of IV antibiotics, fluid bolus, & additional labs if indicated 5

6 Complete your sepsis screening on each shift Communication is KEY! 6

7 sepsis.mednet.ucla.edu Take home points Antibiotics save lives! In sepsis, each hour delay in antibiotic administration increases mortality rate ~10% The first dose of broad-spectrum antibiotics need to be administered w/in 1 hour of TOP All first doses of antibiotics will have a first dose antibiotic sticker and should be tubed to the unit by pharmacy Nurses play an essential role in optimizing the management of septic patients TOP = time of presentation QUESTIONS? 7

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