Antibiotic Selection in Sepsis

by Dr. Brett Margolias

Antibiotic Selection for Patients with Septic Shock (Review)
Critical Care Clinics
Volume 16, Number 2, April 2000

Antibiotic Selection Based on Sourse of Sepsis:

Skin and Soft Tissue Infections - Toxic Shock Syndrome- Caused by Streptococcus pyogenes (Groups
A Beta hemolytic Strep). The Bacteria makes toxins (superantigens) that trigger massive T cell
stimulation and cytokine production causing shock and tissue damage. Treatment includes beta-Lactams
such as penicillin and cephalothin.

Necrotizing Soft Tissue Infections - May be caused by Clostridium perfringes or Clostridium

septicum. These are anaerobic gram positives and can produce secondary infection of ischemic and
necrotic tissues and lead to cellulitis, fasciitis, or myositis. Rapid development of local pain, erythema,
and swelling with foul smelling purulent drainage and gas formation occurs at the site of recent trauma or
surgery. May be hard to distinguish from polymicrobial forms of necrotizing fasciitis. Empiric broad
spectrum antibiotics and emergent surgical debridement are required. Use broad spectrum antibiotics
such as carbepenem or piperacillin-tozobactam combined with aminoglycoside.

Fresh Water Infections - Usually associated with Aeromonas infection. Trimethoprim-sulfamethoxazole

(bactrim), quinolones, third generation cephalosporins, and aminoglycosides are all effective treatments.

Staphylococcus aureus - Common cause of soft tissue and wound infections. May cause
stapholycoccal toxic shock syndrome, again a toxin mediated illness (fever, hypotension, desquamating
rash, diarrhea, and multiorgan dysfunction). Use antistaphylococcal antibiotics.

Nosocomial Pneumonia-

Pseudomonas aeruginosa is the most feared nosocomial infection in the ICU but other bacteria such as
the enteric gram negative bacteria (Enerobacter and Klebsiella) as well as S. aureus are major pathogens
to be feared. Up to 50% of nosocomial pneumonias are polymicrobial. Start patient of empiric broad
spectrum antibiotics. Selection may be based on the most likely pathogen or known bacterial
susceptibility patterns for recent isolates from the specific ICU and hospital. If P.aeruginosa is suspected,
combination therapy with antipseudomonal beta-lactam and an aminoglycoside is indicated. In nursing
home patients a combination of an extended spectrum cephalosporin with clindamycin or the use of beta-
lactam/bata-lactimase inhibitor combination my be a suitable empiric antibiotic choice.

Community-Acquired Pneumonia -

Causes of Community Acquired Pneumonia-

Bacteria - Streptococcus pneumonia, Legionella, Chlamydia pneumoniae, Mycoplasma

pnuemoniae, Aerobic gram negative bacteria, Haemophilus species, Klebsiella species, Escherichia coli,
Enterobacter species, Pseudomonas aeruginosa, Moraxella catarrhalis, Aspiration pneumonia
(polymicrobial anaerobic bacteria).

Viruses - Influenza, Parainfluenza, Adenovirus, Cytomegalovirus, Respiratory Syncitial Virus, Hantavirus.

Fungi - Aspergillosis, Blastomycosis, Cryptocccosis, Histoplasmosis, Coccidiomycossis, Pneumocystis

carinii, Mycobacerium tuberculosis.

Streptococcus Pneumoniae is the most common bacterial cause of community acquired

pneumonia. Neisseria meningitis and Streptococcus pyogenes are uncommon causes of community
acquired pneumonia. Legionella can be a lethal form of pneumonia particularly in patients with advanced
age, chronic lung disease, or compromised cell mediated immunity.

Treatment of Community Acquired Pneumonia - Start with broad spectrum antibiotic therapy to
cover Pneumococcus, nonpseudomonal gram negative bacteria and Legionella.
A macrolide such as erythromycin or azithromycin and a third generation cephalosporin as cefotaxime,
cefriaxone, or ceftizoxime have excellent activity against these pathogens. Quinolones such as
levofloxacin and trovafloxacin can be used as monotheraphy. These agents are effective against
penicillin resistant pneumococci, aerobic gram negative bacteria, and Legionella. Empiric use of
antipseudomonal antibiotics should be considered in certain patients (nursing home residents, patients
recently discharged from the hospital, and patients with cystic fibrosis). For HIV patients use Bactrim to
cover Pneumocystis carinii and a quinalone or macrolide for bacterial pathogen coverage.

Intra-Abdominal Infection-

Spontaneous Bacterial Peritonitis(SBP) - Occurs in patients with underlying chronic liver disease and
ascites. Usually cased by enteric, aerobic gram negative bacteria such E.coli and Kebsiella
rd
pneumoniae. Treat with 3 Generation Cephalosporin.
Peritonitis from Perforation - Polymicrobial (E.coli, Bacteroides fragilis, and enterococci most
frequent). Antibiotics include coverage for enteric, aerobic gram negative bacteria and B.
fragilis. Monotherapy using carbepenem or piperacillin/tazobactam and duel therapy combining a third
generation cephalosporin, a quinalone, or an aminoglycoside with metronidazole is a good start.

Peritonitis in Peritoneal Dialysis Patients - Infection is usually staphylococci (60-80%) . Aerobic gram
negative rods account for up to 20% of cases. Emiric therapy with an antistaphylococcal agent
(cephalothin) and an aminoglycoside is indicated.

Acute Infection of the Biliary System - Organisms usually are enteric bacteria, with polymicrobial
infection being very common. E. coli, Klebsiella, Enterobacter species, and enterococci are
common. Anaerobic bacteria such asBacteroides, and Clostridium can also be isolated. Use same
antibiotic approach as used for Peritonitis from Perforation (see above).

Intravenous Catheter Infection - Gram positive cocci usually responsible, but Enterobacter,
Pseudomonas, Acinetobacter, and Candida are also frequently involved. Empiric antibiotic therapy with
vancomycin and an extended spectrum cephalosporin or aminoglycoside should be initiated after line is
removed.

Bacterial Meningitis -

Streptococcus pneumoniae - The leading cause of bacterial meningitis and is associated with the
highest case fatality rate. It is the most common cause of bacterial meningitis in adults older than 18 and
infants aged 1-23 months.

Neisseria meningitides - The second leading cause of bacterial meningitis and is the most common
agent in children 2-18 years old.

Group B Streptococci (Streptococcus agalactiae) and Listeria monocytogenes are responsible for
greater than 90% of cases of bacterial meningitis within the first month of life. Liseria may also be found
in elderly patients, cancer patients, organ transplant patients, and patients with AIDS.

Haemophilus Influenzae meningitis is a disease of adults or children who have not received the vaccine.

Antibiotics for Meningitis - Empiric antibiotic therapy combining a third generation cephalosporin
(ceftriaxone, cefotaxime) and ampicillin is adequate coverage for the majority of community acquired
pathogens. In areas where invasive pneumococcal isolates demonstrate high level resistance to
penicillin and the prevalence of intermediate or high level resistance to third generation cephalosporins is
significant (>5%) or unknown, the empiric use of vancomycin and a third generation cephalosporin should
be used.

Genitourinary Tract Infections - E.coli is the most common pathogen causing urinary tract infection the
community. Other aerobic gram negatives such as Proteus species and Kebsiella species may also be
found. Nosocomial infections of the urinary tract may be caused by antibiotic resistant organisms such
as Enterobacter and Pseudomonas aerguginosa. A quinolone combined with an aminoglycoside is
reasonable for patients with urinary sepsis.