Streptococcus pneumoniae (pneumococcal) sepsis or septic shock

Australian Commission on Safety and Quality in Health Care (ACSQHC), 2023

In adults and children with pneumococcal sepsis or septic shock not associated with meningitis, use:

benzylpenicillin 2.4 g (child: 60 mg/kg up to 2.4 g) intravenously, 4-hourly. For dosage adjustment in adults with kidney impairment, see benzylpenicillin dosage adjustment. See advice on duration of therapy.benzylpenicillin benzylpenicillin benzylpenicillin

For adults and children who have had a nonsevere (immediate or delayed) or a severe immediate¹ hypersensitivity reaction to a penicillin, use:

1ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, daily. For patients with septic shock or requiring intensive care support, use ceftriaxone 1 g (child 1 month or older: 50 mg/kg up to 1 g) intravenously, 12-hourly². See advice on duration of therapy ceftriaxone ceftriaxone ceftriaxone

1cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For patients with septic shock or requiring intensive care support, use cefotaxime 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, 6-hourly³. For dosage adjustment in adults with kidney impairment, see cefotaxime dosage adjustment. See advice on duration of therapy. cefotaxime cefotaxime cefotaxime

For adults and children who have had a severe delayed⁴ hypersensitivity reaction to a penicillin, use:

1moxifloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, daily⁵. For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment. See advice on duration of therapy moxifloxacin moxifloxacin moxifloxacin

1vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children. Loading doses are recommended for critically ill adults. See advice on duration of therapy. vancomycin vancomycin vancomycin

¹ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

² 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 for patients with septic shock or requiring intensive care support, a modified dosage of ceftriaxone is recommended. Once the critical illness has resolved, consider switching to the standard dosage. If the isolate is not reported to have dose-dependent susceptibility to ceftriaxone (ie susceptible dose dependent [SDD] or susceptible increased exposure [I or SIE]), it may also be appropriate to switch to the standard dosage – seek expert advice.Return

³ 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 for patients with septic shock or requiring intensive care support, a modified dosage of cefotaxime is recommended. Once the critical illness has resolved, consider switching to the standard dosage. If the isolate is not reported to have dose-dependent susceptibility to cefotaxime (ie susceptible dose dependent [SDD] or susceptible increased exposure [I or SIE]), it may also be appropriate to switch to the standard dosage – seek expert advice.Return

⁴ 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

⁵ Moxifloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, clinical trial data suggest that adverse musculoskeletal events are usually mild and short term, similar to those observed in adults. Moxifloxacin can be used in children when it is the drug of choice.Return