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Mild - Moderate
amoxicillin 500mg tds orally & clarithromycin* 500mg bd orally (*MUST review at 48 hours) (If penicillin allergy clarithromycin 500mg bd orally) OR Severe (i.e. 3 or more of CURB-65: confusion, urea>7, RR>30, diastolic BP<60, age>65yr) benzylpenicillin 1.2g qds iv & clarithromycin 500mg bd iv (if penicillin allergy levooxacin 500mg bd iv & clarithromycin 500mg bd iv) Review at 48 hrly intervals, change to oral amoxicillin & clarithromycin. (Patient able to swallow/absorb, temp improving) If pneumonia of severity needing admission to Critical Care use levooxacin 500mg bd iv & benzylpenicillin 1.2g qds iv (If penicillin allergy levooxacin 500mg bd iv & clarithromycin 500mg bd iv) If urinary sepsis also likely, consider adding gentamicin 160mg stat iv (while awaiting microbiology)
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Cellulitis
Mild - Moderate Severe ucloxacillin 1g qds orally (clindamycin 450mg qds orally if penicillin allergic or ucloxacillin failure)
Urine output < 0.5ml/kg/hr for 2 hrs INR > 1.5 or aPTT > 60s Bilirubin > 34mol/l
benzylpenicillin 1.2g qds iv (clindamycin 450mg qds iv if penicillin allergic) PLUS ucloxacillin 1g qds iv NB: If rapidly progressive, +/- shock, severe disproportionate pain consider Necrotising Fasciitis. This is a surgical emergency (must seek senior advice), usual antibiotic therapy is clindamycin and meropenem
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Neutropenic Sepsis
(Neutrophils <1.0x109/L) Tazocin 4.5g tds iv (discuss with SpR Haem) (meropenem 1g tds iv if penicillin allergic)
For complex cases please contact duty microbiologist including if patient recently discharged from hospital, allergy to rst line regimen, infections in pregnancy. Always check for contra-indications, drug interactions, and dosage modication in renal and hepatic impairment.
Feb 2007
If no, treat for SEPSIS: Oxygen Blood cultures IV antibiotics Fluid therapy Reassess for SEVERE SEPSIS with hourly observations
Survive SEPSIS www.survivesepsis.org
Sabina Moolla August 2007 Version: 1
If yes, patient has SEVERE SEPSIS Start SEVERE SEPIS CARE PATHWAY
Negative
YES
No
Severe sepsis, no shock Ensure management plan is documented in notes Ensure hourly obs taken, recorded and acted upon. REASSESS frequently!
Time
Initial
Sepsis Six
YES
No
1. Oxygen: high flow 15l/min via nonrebreathe mask. Target saturations > 94%
2. Blood cultures: take at least one set plus all relevant blood tests eg FBC, U&E, LFT, clotting, glucose.
Consider urine/sputum/swab samples.
Directed Therapy
Time achieved
Initial
1. Ensure Critical Care attend urgently (if not already) 2. Ensure patient has received adequate fluid resuscitation: boluses of 20ml/kg 0.9% saline or Hartmanns to a max of 60ml/kg 3. If still shocked (low BP/low urine output/
high lactate) insert central venous catheter under USS guidance (only if competent; otherwise seek help)
4. Aim to achieve CVP 8-12mmHg with Care Check CVP Monitor 5. Take heparinised sample from central line (use ABG syringe): check ScvO2 > 70% 6. Ensure Hb > 7g/dl: consider transfusion if necessary 7. Consider noradrenaline if still shocked or dobutamine if ScvO2 < 70%
No Sig ............................. Bleep / ID Card No. ..............
6 hour time check: Name .............................................. Designation .....................................
Survive SEPSIS www.survivesepsis.org
Sabina Moolla August 2007 Version: 1
Plus
a. Call Outreach Team if appropriate
One hour time check: all steps done? Name .............................................. Designation .....................................
Survive SEPSIS www.survivesepsis.org
Sabina Moolla August 2007 Version: 1
Yes
Yes
No