Community-associated infected aneurysms in adults with sepsis or septic shock

For patients with infected aneurysms who have sepsis or septic shock, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock. Antibiotics should be administered immediately after 3 sets of blood samples are taken for culture. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.

For empirical therapy of community-associated infected aneurysms in adults with sepsis or septic shock, after taking 3 sets of blood samples for culture (ideally from separate venipuncture sites), a suitable regimen is:

flucloxacillin 2 g intravenously, 4-hourly. For dosage adjustment in adults with kidney impairment, see flucloxacillin intravenous dosage adjustment. See advice on modification and duration of therapy flucloxacillin flucloxacillin flucloxacillin

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vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults. Loading doses are recommended for critically ill adults. See advice on modification and duration of therapy vancomycin vancomycin vancomycin

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ceftriaxone 2 g intravenously, daily. For adults with septic shock or requiring intensive care support, use 1 g intravenously, 12-hourly¹. See advice on modification and duration of therapy. ceftriaxone ceftriaxone ceftriaxone

For adults who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, replace flucloxacillin in the above regimen with:

cefazolin 2 g intravenously, 8-hourly. For adults with septic shock or requiring intensive care support, use 6-hourly dosing¹. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. See advice on modification and duration of therapy. cefazolin cefazolin cefazolin

For patients who have had a severe immediate² hypersensitivity reaction to a penicillin, cefazolin plus vancomycin plus ceftriaxone (at the dosages above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).

For adults who have had a severe delayed³ hypersensitivity reaction to a penicillin, seek expert advice.

¹ Pharmacokinetics may be altered in patients who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure in patients with infected aneurysms who have septic shock or require intensive care support, a modified dosage of ceftriaxone is recommended. Once the critical illness has resolved, consider switching to the standard dosage.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

³ Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return