Empiric Antimicrobial Therapy

All patients with septic shock should receive empiric antimicrobial therapy as soon as possible. Whenever possible, samples of blood or fluids from potential sites of infection should be obtained prior to the initiation of antimicrobial therapy. Selection of antibiotics should be based upon the adequate coverage of all potential pathogens of the potential infection sites as well as the anticipated antimicrobial susceptibility patterns of the bacterial isolate(s).

Empiric therapy should be effective against gram-positive organisms (Streptococcus spp. and Staphylococcus spp.) and gram-negative bacteria. The route of administration should be intravenous in the maximum doses allowed. In neonates, a regimen of ampicillin plus cefotaxime is recommended. For infants one to three months of age, the combination of ampicillin with cefotaxime or ceftriaxone is recommended. In nonimmunocompromised children three months or older, cefotaxime or ceftriaxone is the drug of choice. In adults (non-neutropenic) without an obvious source of infection, a third-generation cephalosporin or an antipseudomonal b-lactamase-susceptible penicillin is recommended. Some experts advise the addition of an aminoglycoside (tobramycin, gentamicin, or amikacin) to this regimen. Alternatively, imipenem or meropenem alone is acceptable. In neutropenic children and adults, ceftazidime, imipenem, or meropenem alone is acceptable. Alternatively, the combination of an antipseudomonal aminoglycoside plus ceftazidime or antipseudomonal b-lactamase-susceptible penicillin is acceptable. In patients with high probability of a gram-positive etiology (history of illicit drug abuse), nafcillin or vancomycin should be added to the regimen. If an anaerobic source is suspected (intraabdominal, biliary, female genital tract, necrotizing cellulitis, aspiration pneumonia, odontogenic infection, or an anaerobic soft tissue infection) metronidazole or clindamycin should be added to the regimen. In patients with potential for Legionella species infection, the addition of erythromycin to the regimen is recommended. In patients with indwelling vascular devices, vancomycin should be added to the regimen.

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