Prehospital management of sepsis or septic shock

Arrange urgent transfer of patients with suspected sepsis or septic shock to hospital and start resuscitation.

Take blood samples for culture and administer an immediate dose of antibiotic if:

arrival at a hospital is likely to be delayed by 1 hour or more (such as in regional, rural or remote areas), or
meningococcaemia is suspected on clinical grounds (eg fever plus purpuric rash, sepsis plus meningeal symptoms, unexplained septic shock in young adults) – meningococcal sepsis may be rapidly fatal (see Prehospital management of suspected meningitis).

Antibiotic choice should be based on local protocols, if available.

For neonates with suspected sepsis or septic shock in the community, in the absence of local protocols, use:

1cefotaxime 50 mg/kg intravenously or intramuscularly¹ ² cefotaxime

OR

1benzylpenicillin 90 mg/kg intravenously or intramuscularly³ ⁴. benzylpenicillin

For adults and children 1 month or older with suspected sepsis or septic shock in the community, in the absence of local protocols, use:

ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously or intramuscularly. For advice on reconstitution and administration, see Preparation of ceftriaxone for intravenous administration for suspected sepsis or septic shock for intravenous doses and Preparation of ceftriaxone for intramuscular administration for suspected sepsis or septic shock for intramuscular doses. ceftriaxone ceftriaxone ceftriaxone

If ceftriaxone is not available, seek expert advice. Benzylpenicillin may be a suitable, and readily available, alternative.

Ceftriaxone can be used in patients who have had a severe immediate⁵ or nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, but not in those who have had a severe delayed⁶ hypersensitivity reaction to a penicillin. For patients with severe delayed hypersensitivity to penicillins, seek expert advice.

Urgent administration of empirical antibiotics is required once the patient is admitted to hospital, even if antibiotics were given before admission.

Table 1. Preparation of ceftriaxone for intravenous administration for suspected sepsis or septic shock
The Royal Children's Hospital Melbourne (RCH), 2021 The Society of Hospital Pharmacists of Australia (SHPA), 2024
Reconstitute the vial Reconstitute the vial (Ceftriaxone AFT [NB1]) to achieve an initial ceftriaxone concentration of 100 mg/mL 500 mg vial: add 4.7 mL WFI 1 g vial: add 9.4 mL WFI 2 g vial: add 18.9 mL WFI Prepare a dilute solution Further dilute the reconstituted solution to achieve a final concentration of 40 mg/mL 500 mg vial: add 7.5 mL of sodium chloride 0.9% 1 g vial: add 15 mL of sodium chloride 0.9% 2 g vial: add 30 mL of sodium chloride 0.9% Determine the volume to administer Determine the final volume to be administered according to the recommendations below.
Age	Dose	Administration instructions
child 1 month or older weighing less than 40 kg	50 mg/kg up to 2 g	Calculate the dose eg for a 20 kg child: 50 mg/kg × 20 kg = 1000 mg Calculate the volume of dilute solution eg for a 20 kg child: 1000 mg ÷ 40 mg/mL = 25 mL Administer: doses 1 g or less: over 5 minutes doses more than 1 g: over at least 30 minutes [NB2]
adult or child weighing 40 kg or more	2 g	Administer the dose (50 mL of diluted solution) over 30 minutes [NB2]
Note: WFI = water for injection NB1: Ceftriaxone powder volumes vary depending on the brand used. The advice in this table is specific to the Ceftriaxone AFT brand. NB2: Some centres may administer doses more than 1 g over 5 to 15 minutes.

Table 2. Preparation of ceftriaxone for intramuscular administration for suspected sepsis or septic shock
The Royal Children's Hospital Melbourne (RCH), 2021 The Society of Hospital Pharmacists of Australia (SHPA), 2024
Reconstitute the vial Reconstitute the vial (Ceftriaxone AFT [NB1]) to achieve a ceftriaxone concentration of 250 mg/mL [NB2] [NB3] 500 mg vial: add 1.7 mL WFI or lidocaine 1% 1 g vial: add 3.4 mL WFI or lidocaine 1% 2 g vial: add 6.9 mL WFI or lidocaine 1% Determine the volume to administer Determine the final volume to be administered according to the recommendations below.
Age	Dose	Administration instructions
child 1 month or older weighing less than 40 kg	50 mg/kg up to 2 g	Calculate the dose eg for a 20 kg child: 50 mg/kg × 20 kg = 1000 mg Calculate the volume eg for a 20 kg child: 1000 mg ÷ 250 mg/mL = 4 mL Administer the dose by deep intramuscular injection into a large muscle Consider dividing the dose among multiple injection sites to minimise pain
adult or child weighing 40 kg or more	2 g	Administer the dose (8 mL) by deep intramuscular injection into a large muscle Consider dividing the dose among multiple injection sites to minimise pain
Note: WFI = water for injection NB1: Ceftriaxone powder volumes vary depending on the brand used. The advice in this table is specific to the Ceftriaxone AFT brand. NB2: Some centres use ceftriaxone concentrations up to 350 mg/mL in children. The Royal Children's Hospital Melbourne (RCH), 2021 NB3: Lidocaine 1% can be used when the dose will be given intramuscularly; it must not be used if the dose is to be given intravenously.

¹ For intravenous administration of cefotaxime in neonates, reconstitute a 0.5 g vial with 9.8 mL of water for injection to make a 50 mg/mL solution, or a 1 g vial with 9.6 mL of water for injection to make a 100 mg/mL solution. Calculate the required volume and administer the dose over 3 to 5 minutes. These recommendations are based on the Australasian Neonatal Medicines Formulary; use local protocols, where possible.Return

² For intramuscular administration of cefotaxime in neonates, reconstitute a 0.5 g vial with 2 mL of water for injection to make a 230 mg/mL solution, or a 1 g vial with 3 mL of water for injection to make a 300 mg/mL solution. Calculate the required volume and inject the dose deep into a large muscle. These recommendations are based on the Australasian Neonatal Medicines Formulary; use local protocols, where possible.Return

³ For intravenous administration of benzylpenicillin in neonates, reconstitute the vial, further dilute the solution to a final concentration of 30 mg/mL, then calculate the required volume and administer the dose over at least 30 minutes. These recommendations are based on the Australasian Neonatal Medicines Formulary; use local protocols, where possible. For a 0.6 g vial, reconstitute with 3.6 mL of water for injection to make a 150 mg/mL solution, then draw up 3 mL (450 mg of penicillin) of solution and add to 12 mL of sodium chloride 0.9%. Calculate the required volume and administer the dose over at least 30 minutes. For a 1.2 g vial, reconstitute with 3.2 mL of water for injection to make a 300 mg/mL solution, then draw up 2 mL (600 mg penicillin) of solution and add to 18 mL of sodium chloride 0.9%. Calculate the required volume and administer the dose over at least 30 minutes. For a 3 g vial, reconstitute with 8 mL of water for injection to make a 300 mg/mL solution, then draw up 2 mL (600 mg penicillin) and add to 18 mL of sodium chloride 0.9%. Calculate the required volume and administer the dose over at least 30 minutes. Return

⁴ For intramuscular administration of benzylpenicillin in neonates, prepare a 300 mg/mL solution. Reconstitute a 0.6 g vial with 1.6 mL of water for injection, a 1.2 g vial with 3.2 mL of water for injection, or a 3 g vial with 8 mL of water for injection. Calculate the required volume and inject the dose deep into a large muscle. These recommendations are based on the Australasian Neonatal Medicines Formulary; use local protocols, where possible.Return

⁵ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

⁶ 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