Pre-hospital and Community Hospital use of antibiotics for treatment of sepsis in adults

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Administration of intravenous antibiotics in the community to patients with suspected sepsis is challenging.  Many of the recommended antibiotic combinations in the current Management of Infection Guidance are not suitable for administration in the community setting as they include infusions and complex dose calculations according to renal function.  The following information is designed for use by practitioners assessing and providing initial management of patients with suspected sepsis in the community.  The agents chosen can all be given by bolus intravenous injection and some by intramuscular injection.  A number of oral or per rectum options are also given.

Alternative option (if only have stock drugs in GP bag or OOHs centre)

Please note a change of dose. For further information on reconstitution see: Medusa and SPC

Indication	First line	Beta-lactam anaphylaxis	Notes
Meningitis	Benzyl penicillin 1.2g IV/IM OR Ceftriaxone OR cefotaxime 2g IV/IM (For IM administration: administer as 2 separate 1g injections at separate sites and reconstitute with 1% lidocaine to reduce pain at the injection site)	Chloramphenicol* 25mg/kg IV	Doses as per existing guidelines
Sepsis of unknown origin	Ceftriaxone OR cefotaxime 2g IV/IM (For IM administration: administer as 2 separate 1g injections at separate sites and reconstitute with 1% lidocaine to reduce pain at the injection site)	Chloramphenicol* 25mg/kg IV

* Chloramphenicol injection should be held as stock in rural areas for use in patients with confirmed anaphylaxis to penicillin as use of cephalosporin not advised in these patients.

Preferred option (ONLY if a range of antibiotic injections are available)

Administer the most appropriate antibiotic available, preferably intravenously (IV), depending on likely sepsis source.  This guidance applies in a community hospital setting where a greater range of medications are available.  If intravenous access not available, administer intramuscularly (IM) (if drug suitable) or high dose oral if patient can take. 

Indication	First line	Beta-lactam anaphylaxis	Notes
Meningitis	IV/IM benzyl penicillin OR IV/IM ceftriaxone/cefotaxime	Chloramphenicol 25mg/kg IV	Doses as per existing guidelines
Sepsis of unknown origin	Amoxicillin 1g IV/IM PLUS Aztreonam 2g IV/IM PLUS Metronidazole 800mg (oral) OR 1g (PR)	Teicoplanin 800mg IV/IM in place of amoxicillin and flucloxacillin, rest as before (If the patient weighs less than 65kg, give 400mg teicoplanin)	If Staphylococcus aureus infection suspected: ADD flucloxacillin 2g IV/IM Note max single IM dose is 500mg per site. Give 2g dose over 4 injection sites.
Respiratory	Amoxicillin 1g IV/IM PLUS Doxycycline 200mg (oral)	Levofloxacin 500mg (oral) (see BNF warnings and MHRA Drug Safety Alert)	Aspiration pneumonia: ADD Metronidazole 800mg (oral) OR 1g (PR)
UTI	Aztreonam 2g IV/IM	Ciprofloxacin 750mg twice daily (oral) (see BNF warnings and MHRA Drug Safety Alert)	Co-amoxiclav 625mg (oral)
SSTI	Flucloxacillin 2g IV/IM Note max single IM dose is 500mg per site. Give 2g dose over 4 injection sites.	Teicoplanin 800mg IV/IM (If the patient weighs less than 65kg, give 400mg teicoplanin)	If no teicoplanin, give cefotaxime 1g IV/IM
Intra-abdominal sepsis	As for sepsis of unknown origin (flucloxacillin not required).

For glossary of terms see Glossary