Hospital-acquired sepsis or septic shock in adults at risk of infection with multidrug-resistant gram-negative bacteria
For adults with hospital-acquired sepsis or septic shock of unknown source who are at risk of infection with multidrug-resistant gram-negative bacteria, while awaiting results of susceptibility testing and expert advice, consider empirical therapy withAbdul-Aziz, 2024Dulhunty, 2024:
patients without suspected neurological infection or septic shock and not requiring intensive care support: 1 g 8-hourly
patients with suspected neurological infection, but without septic shock and not requiring intensive care support: 2 g 8-hourly; administer the dose over 3 hours1
patients with septic shock or requiring intensive care support: 2 g administered as a loading dose over 30 minutes. After 4 hours, administer 2 g 8-hourly, as consecutive 8-hour infusions23
PLUS
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 for critically ill adults. vancomycin vancomycin vancomycin
For adults in whom toxic shock syndrome is suspected4, add to the above regimen:
clindamycin 600 mg intravenously, 8-hourly for a minimum of 72 hours and until organ function has significantly improved5 clindamycin clindamycin clindamycin
PLUS
intravenous immunoglobulin (IVIg) 2 g/kg intravenously, as a single dose as soon as possible but not later than 72 hours. It is reasonable to give the dose in divided doses if it is not possible to give a single dose.
For adults at risk of invasive Candida infection, consider the addition of an empirical antifungal.
If infection with carbapenem-resistant gram-negative bacteria (including carbapenemase-producing Enterobacterales) is suspected, the meropenem plus vancomycin regimen above may be given while awaiting advice from a clinical microbiologist or infectious diseases physician. Alternatively, if available, follow local guidelines.
See Managing suspected infection with multidrug-resistant gram-negative bacterium for advice on obtaining a thorough history in patients with suspected multidrug-resistant gram-negative infection, practical information on common acquired resistance mechanisms, and antimicrobials that may remain effective against multidrug-resistant gram-negative bacteria. However, this advice is not a substitute for expert advice – always consult a clinical microbiologist or infectious diseases physician.
This empirical regimen is intended for initial therapy only (up to 48 hours). Modify therapy as soon as additional information is available (eg source of infection, results of Gram stain, culture and susceptibility testing). Evaluate the appropriateness of antimicrobial therapy daily, with consideration given to the patient’s clinical status and the principles of antimicrobial stewardship.