Sepsis Adult FIRST DOSE Empirical

Intravenous Antibiotic Guideline v2.1

The Clinical Excellence Commission Sepsis Adult FIRST DOSE Empirical Intravenous Antibiotic Guideline aims to guide
the prescription and timely administration of the FIRST DOSE of intravenous (IV) antibiotics for adult patients who
have a diagnosis of sepsis. The guideline is based on the Therapeutic Guidelines: Antibiotic version 14, 20101 and
incorporates best available evidence2,3 and the principles of appropriate use of antibiotics. The Guideline is intended to
provide an accessible resource which can be adapted to suit individual facility preferences as required.

Prompt administration of antibiotics and resuscitation fluids is vital in the management of the patient with sepsis.
The goal is to commence antibiotic therapy within the first hour of diagnosis of sepsis.
Review of antibiotics once results are known is required to facilitate targeted therapy.

Table 1: Antibiotic Prescribing

If renal failure is present, dosages and intervals of antibiotics may need to be adjusted in particular for vancomycin,
gentamicin and penicillin drugs. See Therapeutic Guidelines: Antibiotic version 14, 2010
ALL penicillin and cephalosporin class antibiotics are contraindicated in patients with history of DRESS (drug rash
with eosinophilia and systemic symptoms), Stevens-Johnson syndrome or IgE-mediated penicillin or cephalosporin
allergy
Obtain two sets of blood cultures before administering antibiotics: CEC Sepsis Adult Blood Culture Sampling
Guideline 2012 v2
Obtain other clinical specimens as appropriate but do not delay administration of antibiotics or wait for results of
investigations. Contact the ID Physician/Microbiologist on call to seek advice as needed.

Table 2: Antibiotic Administration

Administer the antibiotic which takes the least time to inject or infuse balancing this with administering the most
needed/effective antibiotic for the organism suspected of causing the sepsis
Reconstitute antibiotics with sterile water for injection unless stated otherwise
If further dilution is required for IV injection or infusion, use sterile sodium chloride 0.9% or sterile glucose 5%
unless stated otherwise
To avoid drug incompatibility without delaying fluid administration, flush the IV line with sterile sodium chloride
0.9% before and after the antibiotic injection/infusion
Where possible use separate dedicated lines for resuscitation fluid and for medications.

Special considerations
Vancomycin* The first dose is a loading dose based on the patient’s actual body weight.
Subsequent doses and intervals will be based on the patient’s GFR and creatinine clearance. Please see eTG for further
information.
Loading dose IV vancomycin. Infuse at 10mg/minute
Patient’s actual body weight (kg) <60kg 60-80kg 80-100kg >100kg*
LOADING DOSE 1 gram 1.5 grams 2 grams 2.5grams
*Subsequent doses and dosing intervals are based on calculated creatinine clearance (not eGFR):
http://www.mdcalc.com or http://proxy9.use.hcn.com.au/tgc/abg/creat.htm ; seek ID/Micro advice
Gentamicin** dose relates to lean body weight. A ‘one dose’ instruction rather than a dosing frequency indicates the
need for review of renal function and specimen results to deliver appropriate, targeted therapy.
When administering ampicillin followed by gentamicin, do not wait between infusions. Flush the IV line well.

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Table 1: Antibiotic Prescribing
Likely source of sepsis
Severe sepsis, unknown
source and the patient is
immunocompetent
Consider adding vancomycin if
there is a higher risk of MRSA
infection
Severe sepsis and
meningococcal infection
suspected
Severe sepsis and toxin
mediated shock likely or
present (seek advice for
diagnosis of toxic shock
syndrome)
Febrile neutropenia
Febrile neutropenia and
shocked or possible catheter
related infection
SEVERE Community acquired
pneumonia
(USE SMART-COP or CORB for
scoring)
Urinary source likely e.g.
pyelonephritis
CEC Sepsis Adult First Dose Empirical
Intravenous Antibiotic Guideline
Empirical antibiotic
regimen
flucloxacillin 2g IV, 6-hourly
plus
gentamicin** 7mg/kg IV, for 1
dose (max 640 mg)
ADD
benzyl penicillin 1.8g IV,
4-hourly
ADD
lincomycin 600mg IV,
8-hourly
OR
clindamycin 600mg IV,
8-hourly
piperacillin 4g & tazobactam
500mg IV, 8-hourly
plus
gentamicin** 7mg/kg IV, for
1 dose (max 640 mg)
ADD
vancomycin* 1 to 2.5g IV
loading dose
ceftriaxone 1g IV, daily
plus
azithromycin 500mg IV, daily
ampicillin 2g IV, 6-hourly
plus
gentamicin** 7mg/kg IV,
for 1 dose (max 640 mg)
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Penicillin hypersensitivity
cephazolin 2g IV,8-hourly
plus
gentamicin** 7mg/kg IV, for 1
dose (max 640 mg)
ADD
ceftriaxone 2g IV, 12-hourly
ADD
lincomycin 600mg IV,
8-hourly
OR
clindamycin 600mg IV,
8-hourly
cefepime 2g IV, 8-hourly
plus
gentamicin** 7mg/kg IV, for
1 dose (max 640 mg)
ADD
vancomycin* 1 to 2.5g IV
loading dose
ceftriaxone 1g IV, daily
plus
azithromycin 500mg IV, daily
ceftriaxone 1g IV, daily
Penicillin anaphylaxis
vancomycin* 1 to 2.5g IV
loading dose
plus
gentamicin** 7mg/kg IV, for 1
dose (max 640 mg)
ADD
moxifloxacin 400mg IV daily
ADD
lincomycin 600mg IV,
8-hourly
OR
clindamycin 600mg IV,
8-hourly
vancomycin* 1 to 2.5g IV
loading dose
plus
gentamicin** 7mg/kg IV, for
1 dose (max 640 mg)
moxifloxacin 400mg IV, daily
plus
azithromycin 500mg IV, daily
gentamicin** 7mg/kg IV, for
1 dose (max 640 mg)
and seek ID/Micro advice
Clinical Excellence Commission 2012
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 CEC Sepsis Adult First Dose Empirical
Intravenous Antibiotic Guideline

Likely source of sepsis Empirical antibiotic Penicillin hypersensitivity Penicillin anaphylaxis

regimen

ampicillin 1g IV, 6-hourly ceftriaxone 1g IV, daily seek ID/Micro advice

plus plus
gentamicin** 7mg/kg IV, for 1 metronidazole 500mg IV,
Intra-abdominal source likely
dose (max 640 mg) 12-hourly
plus
metronidazole 500mg IV,
12-hourly

Neurological ceftriaxone 2g IV, 12-hourly ceftriaxone 2g IV, 12-hourly vancomycin* 1 to 2.5g IV

loading dose
Steroids may be indicated;
plus and seek ID/MICRO advice plus
see TG: antibiotic v 14, 2010
benzyl penicillin 2.4g IV, moxifloxaxin 400mg IV, daily
4-hourly (if at risk for Listeria
infection)
and seek ID/MICRO advice and seek ID/MICRO advice

Skin flucloxacillin 2g IV, 6-hourly cephazolin 2g IV, 8-hourly lincomycin 600mg IV, 8-hourly
OR
Consider adding vancomycin if
clindamycin 600mg IV,
there is a higher risk of MRSA
8-hourly
infection
OR
vancomycin* 1 to 2.5g IV
loading dose

Female genital tract ceftriaxone 1g IV, daily ceftriaxone 1g IV, daily lincomycin 600mg IV, 8-hourly
plus plus OR
azithromycin 500mg IV, daily azithromycin 500mg IV, daily clindamycin 600mg IV, 8-
hourly
plus plus plus
metronidazole 500mg IV, metronidazole 500mg IV, gentamicin** 7mg/kg IV, for 1
12-hourly 12-hourly
dose (max 640 mg)

IV line related vancomycin* 1 to 2.5g IV vancomycin* 1 to 2.5g IV vancomycin* 1 to 2.5g IV

loading dose loading dose loading dose
NB remove line
plus plus plus
gentamicin** 7mg/kg IV, gentamicin** 7mg/kg IV, gentamicin** 7mg/kg IV,
for 1 dose (max 640 mg) for 1 dose (max 640 mg) for 1 dose (max 640 mg)

With thanks to Liverpool Hospital Emergency Department for the use of their Empirical Intravenous Antibiotic Guideline which forms the basis of Table 1.

References:
1. Antibiotic Expert Group. Therapeutic Guidelines: antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited; 2010
2. Burridge N., Deidun, D. (Ed) (2008) Australian injectable drugs handbook (4th Ed). Collingwood: The Society of Hospital
Pharmacists Australia.
3. Rossi S. (Ed) (2011) Australian Medicines Handbook. Adelaide: Australian Medicines handbook Pty Ltd.
4. Loewenthal, M.R., Dobson, P.M. (2010) Tobramycin and gentamicin can safely be given by slow push. Journal of Antimicrobial
Chemotherapy. 65(9):2049-50.

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 CEC Sepsis Adult First Dose Empirical
Intravenous Antibiotic Guideline

Table 2: Antibiotic Administration

Minimum
Presentation Reconstitution
Antibiotic Final volume* administration Notes
(adult) fluid / volume
time
Vial
ampicillin 1g 10 mL WFI 10 - 20 mL 3 – 5 minutes Penicillin class antibiotic

4.8 mL WFI, Concentration must be 1 or 2

Vial then add to mg/mL to avoid local infusion
azithromycin infusion fluid 250 mL 500 mL 60 minutes site reaction. Rare reports of
500 mg
bag prolonged QT interval
Vials Penicillin class antibiotic.
benzyl penicillin 600 mg 2 mL WFI 10 - 20 mL 3 – 5 minutes Consider administering doses ≥
1.2 g 2.4 g over 30 minutes
4 mL WFI
Vial
cefepime 1g 10 mL NS 10 mL 3 - 5 minutes Cephalosporin class antibiotic

Vials Cephalosporin class antibiotic.

Incompatible with calcium
ceftriaxone 1g 10 mL WFI 10 - 20 mL 2– 4 minutes containing solutions, flush
thoroughly before and after
2g 20 mL WFI 50 mL 30 minutes with sodium chloride 0.9%
Vial
cephazolin 1g 10 mL WFI 10 - 20 mL 3 – 5 minutes Cephalosporin class antibiotic

Ampoules 600 mg in 50 mL 20 minutes

Check product is clear of any
clindamycin 300 mg/2 mL N/A
900 mg in 100 crystals prior to administration
600 mg/4 mL 30 minutes
mL
Vial 10 mL 3 - 5 minutes (1 g)
flucloxacillin 1g 5 mL WFI Penicillin class antibiotic
50 mL 30 minutes (2 g)
(240mg or less) Some centres may give up to
10- 20 mL
3 – 5 minutes 640mg IV push over 3 – 5
Ampoule
gentamicin N/A minutes; refer to Reference 4:
80 mg/2 mL (more than 240 mg) Loewenthal MR & Dobson PM 2010
50 -100 mL
30 minutes J Antimicrob Chemoth
Vial 600 mg in 100
lincomycin 600 mg/2 mL N/A 60 minutes
mL
Infusion bag See presentation
metronidazole 500 mg/100 mL N/A 20 minutes
column
May prolong QT interval and
Infusion bag See presentation lead to ventricular arrhythmias.
moxifloxacin N/A 60 minutes May induce seizures in
400 mg /250 mL column
epileptics
piperacillin with Vial
4 g /0.5 g 20 mL WFI 50 mL 30 minutes Penicillin class antibiotic
tazobactam
ticarcillin with Vial
3 g/0.1 g 13 mL WFI 50 mL 30 minutes Penicillin class antibiotic
clavulanic acid
Infusion related effects are
Maximum of common, decrease infusion
vancomycin Vials 1 g / 200 mL rate and monitor closely if
10mg/minute
these occur

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