Empirical therapy for arthroplasty device infection in patients with symptoms or signs of sepsis or septic shock
Administration of the first dose of antibiotics must not be delayed in patients with a suspected arthroplasty device infection and symptoms or signs of sepsis or septic shock. Give antibiotics within 1 hour of the patient presenting to medical care or, for a ward-based patient, developing sepsis or septic shock; antibiotics should be given immediately after appropriate samples are taken for culture. Two sets of blood for culture should always be taken before antibiotic administration. A joint aspirate should be collected as soon as possible, but should not delay antibiotic administration. For nonantibiotic management of sepsis or septic shock, see Early intervention for sepsis or septic shock.
Broad-spectrum initial therapy is recommended for all patients with symptoms or signs of sepsis or septic shock, regardless of the classification of the infection. The choice of cefepime, ciprofloxacin or gentamicin (or for patients with immediate severe or delayed severe hypersensitivity to penicillins, the choice of ciprofloxacin or gentamicin) for empirical treatment of Gram-negative organisms should be determined by local epidemiology (if known), local antimicrobial stewardship policy and drug availability. Broader Gram-negative activity may be required in patients with risk factors for infection with multidrug-resistant Gram-negative bacterium—seek expert advice.
Modify therapy as soon as additional information is available (eg results of Gram stain, culture and susceptibility testing) (see Directed antibiotic therapy for arthroplasty device infections). If the results of culture or susceptibility testing are not available by 72 hours or if the culture results are negative, seek expert advice on rationalising therapy. Evaluate appropriateness of antibiotic therapy daily, with consideration given to the patient’s clinical status and the principles of antimicrobial stewardship.
For empirical therapy for patients with a suspected arthroplasty device infection and symptoms or signs of sepsis or septic shock, while awaiting infectious diseases or clinical microbiology advice, useAbdul-Aziz 2024Dulhunty 2024:
vancomycin 25 mg/kg (actual body weight) rounded up to nearest 125 mg, up to 3 g intravenously, as a loading dose. See Calculated vancomycin loading dosage in critically ill adults for calculated weight-based loading doses. Subsequent doses are dependent on weight and kidney function; see Intermittent vancomycin dosing in critically ill adults vancomycin vancomycin vancomycin
PLUS one of the following
1cefepime 2 g intravenously, 8-hourly1. For dosage adjustment in adults with kidney impairment, see cefepime dosage adjustment cefepime cefepime cefepime
OR
1ciprofloxacin 400 mg intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment ciprofloxacin ciprofloxacin ciprofloxacin
OR
1gentamicin intravenously; see Gentamicin initial dose calculator for adults for initial dose. See Principles of aminoglycoside use for prescribing considerations and subsequent dosing. gentamicin gentamicin gentamicin
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, while awaiting infectious diseases or clinical microbiology advice, use vancomycin plus cefepime, ciprofloxacin or gentamicin (see dosages above).
In patients who have had a severe (immediate or delayed) hypersensitivity reaction to a penicillin, while awaiting infectious diseases or clinical microbiology advice, use:
vancomycin 25 mg/kg (actual body weight) rounded up to nearest 125 mg, up to 3 g intravenously, as a loading dose. See Calculated vancomycin loading dosage in critically ill adults for calculated weight-based loading doses. Subsequent doses are dependent on weight and kidney function; see Intermittent vancomycin dosing in critically ill adults vancomycin vancomycin vancomycin
PLUS EITHER
1ciprofloxacin 400 mg intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment ciprofloxacin ciprofloxacin ciprofloxacin
OR
1gentamicin intravenously; see Gentamicin initial dose calculator for adults for initial dose. See Principles of aminoglycoside use for prescribing considerations and subsequent dosing.gentamicingentamicin gentamicin