vasile
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Hi guys I wander if any of you use Augumentin in your clinical practice and if you have any link to your guidelines where it suggest in what scenarios can be used.Many thanks!
Augmentin
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unleashedfury
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Augumentin as in the Antibiotic?
I couldn't see how it would play in the prehospital field
I couldn't see how it would play in the prehospital field
OP
OP
vasile
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SIRS or septic patients where travel time is over 40 minutes .
Totally agree.
Curious why the OP picked Augmentin as an example. It's rarely used IV, and there are far better choices.
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blindsideflank
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You dont see the use of an antibiotic or this particular drug?
There is a ton of evidence regarding the huge increase in morbidity and mortality from delayed abx in sepsis.
I can't give you anything written but I know of services that go through the sirs criteria including lactate and have to draw cultures before administration
Now what is this called? Sirs is easy. Sepsis refers to sirs with a known infection, shock is indicated by the lactate (or by clinical findings). Some call it sirs shock I guess
Question: I am told you must draw cultures before antibiotics begin. What about urinalysis?
There is a ton of evidence regarding the huge increase in morbidity and mortality from delayed abx in sepsis.
I can't give you anything written but I know of services that go through the sirs criteria including lactate and have to draw cultures before administration
Now what is this called? Sirs is easy. Sepsis refers to sirs with a known infection, shock is indicated by the lactate (or by clinical findings). Some call it sirs shock I guess
Question: I am told you must draw cultures before antibiotics begin. What about urinalysis?
Ewok Jerky
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Administering ABXs without a culture can be tricky. If you are going to give empiric therapy it should be guided by Pt Hx, suspected source, local resistance patterns etc...not really by "protocol". While B-lactams have a role in empiric therapy, they are not always the best choice. Also, the last thing I want with a septic/SIRS Pt 40+ minutes out from the hospital is a reaction to sulfa.
Cultures will tell you what bug you are dealing with , allowing you to choose the most effective ABX. Sepsis can be cultured from blood. UTIs, cystitis, pyeloniphritis etc. can be cultured from UA.
unleashedfury
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This suspected sepsis based on clinical findings or other suspected infections in prehospital is just that. Suspected we do not have enough tools to confirm infections. you still need cultures Docs just don't look at a patient and say yep you got an infection heres some antibiotics. they still run tests, labs and xrays for chest infections to prove their diagnosis.
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The use of abx in the field without pre admin blood cultures is a bad idea. In some cases you may be killing a mosquito with a cannon, in others you may be using a fly swatter to kill an alligator. Not to mention the fact that depending on the bug, it may just walk right past the abx as if they were not even there.
In suspected neonatal sepsis we would start empiric abx therapy after pre admin cultures were drawn, and then refine the antibiotic of choice after the cultures had time to grow and show what we were dealing with.
In suspected neonatal sepsis we would start empiric abx therapy after pre admin cultures were drawn, and then refine the antibiotic of choice after the cultures had time to grow and show what we were dealing with.
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And just to address the OP a bit more specifically, amoxicillin was not at the top of our list for treatment if sepsis, which is the only reason I could see justifying use of abx prehospitally (cultures drawn and extended transport time.)
Vancomycin and gentamicin come to mind as abx the abx of choice for us.
Vancomycin and gentamicin come to mind as abx the abx of choice for us.
JPINFV
Gadfly
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Um... yes we do. We're going to start ABX on any septic patient based off of SIRS criteria, unless we have a reason not to (I go for a jog with a cold, I'm technically in sepsis) ASAP. We'll generally wait for a CBC. We're generally not waiting on a lactate, and we're definitely not waiting for a culture (blood cultures aren't negative until 2 days have gone without growth).
That said, we still have a UA, chest x-ray, and a better physical exam (how often are you flipping and stripping your non-trauma patients? How many critical patients are in the ED with more than underwear and a gown on?) to go on for finding a source.
This is all doubly so if they're in severe sepsis (hypotension treated with fluids or end organ damage) or septic shock (hypotension refractory to fluids).
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I really don't see any reason to do prehospital cultures. They can draw them in the ED.
For that matter, I really don't see the point in prehospital lactate either, to be honest. Will you not treat someone with clinical signs of sepsis just because their lactate is normal? Will you give ABX to someone with an elevated lactate even if they have no clinical signs of sepsis? Are your transports long enough that trending lactate is really useful?
If you really want to treat sepsis in the field, then clinical signs of sepsis = empiric ABX and IVF to a MAP of >65. You don't need a lactate or a WBC. If it turns out you were wrong and there was some other cause of their SIRS, a single dose of ABX is probably not going to cause a problem. I don't know how practical it is to carry vancomycin and Zosyn on an ambulance, though.
Didn't the Surviving Sepsis guidelines change to reflect the lack of evidence that it really mattered when the ABX were given? IIRC, the old guidelines called for ABX to be given within 1 hour of presentation, and the new ones call for them to be given within 3 hours.
For that matter, I really don't see the point in prehospital lactate either, to be honest. Will you not treat someone with clinical signs of sepsis just because their lactate is normal? Will you give ABX to someone with an elevated lactate even if they have no clinical signs of sepsis? Are your transports long enough that trending lactate is really useful?
If you really want to treat sepsis in the field, then clinical signs of sepsis = empiric ABX and IVF to a MAP of >65. You don't need a lactate or a WBC. If it turns out you were wrong and there was some other cause of their SIRS, a single dose of ABX is probably not going to cause a problem. I don't know how practical it is to carry vancomycin and Zosyn on an ambulance, though.
Didn't the Surviving Sepsis guidelines change to reflect the lack of evidence that it really mattered when the ABX were given? IIRC, the old guidelines called for ABX to be given within 1 hour of presentation, and the new ones call for them to be given within 3 hours.
blindsideflank
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Absolutely agree with the lactate comment.
Are you saying the antibiotic will not affect the culture taken later? I didn't know this. It sure removes a barrier (mostly labs not trusting our draws)
All my knowledge still holds the treatment standard at one hour. I have a friend that has looked heavily into this and I will contact him for his opinion and sources
Are you saying the antibiotic will not affect the culture taken later? I didn't know this. It sure removes a barrier (mostly labs not trusting our draws)
All my knowledge still holds the treatment standard at one hour. I have a friend that has looked heavily into this and I will contact him for his opinion and sources
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I'm no expert on this stuff, but I think it stands to reason that if someone has a bacteremia sufficient to cause SIRS, the micro lab will still be able to grow it out after a single dose of ABX.
I know when I worked in the ED we would always try to get 2 sets of cultures before giving ABX, but some people are tough to draw a sufficient amount of blood from and if it was taking more than a few minutes, getting the ABX in ASAP was always considered a much higher priority. This was back when really early admin of ABX was stressed, which again, I think is less the case than it used to be. Also when I worked in the ICU we would get cultures every few days on people whose sepsis wasn't improving, and this was on people who'd usually been on ABX for days already.
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To my knowledge, cultures prior to abx is best practice.
It does happen from time to time that an outlying facility would start empiric therapy prior to drawing a culture, but the cultures would be drawn immediately on our arrival.
You may not think that antibiotic admin would have that much of an effect on what grows out on cultures, but the IV antibiotic is systemic as soon as it hits the vein, and an hour or two of administration prior to drawing labs will certainly have an effect on what/how much grows on a culture.
It does happen from time to time that an outlying facility would start empiric therapy prior to drawing a culture, but the cultures would be drawn immediately on our arrival.
You may not think that antibiotic admin would have that much of an effect on what grows out on cultures, but the IV antibiotic is systemic as soon as it hits the vein, and an hour or two of administration prior to drawing labs will certainly have an effect on what/how much grows on a culture.
Brandon O
Puzzled by facies
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There may be an even greater benefit to simply guaranteeing that these patients are triaged into the sepsis pathway. But I do wonder how reliably field providers can differentiate who qualifies (versus simple infection); throwing around broad-spectrum antibiotics won't do us any good in the resistance battle.
Lactate, or a reasonable clinical algorithm, could be a reasonable approach.
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My point is that if a patient is in such a state that we are confident they are septic and sick enough that we feel ABX and resuscitation should be implemented as early as possible, then cultures are not a priority and lactate is merely a confirmatory finding.
With the exception of antibiotics, sepsis management is really just general supportive care, so if you go about managing the patient, is doesn't really matter whether their SIRS is from sepsis or another cause.
Personally, I don't think ABX is appropriate or necessary in the field in most cases. Unless you have very long transports, in which case labs and ABX might be beneficial.
With the exception of antibiotics, sepsis management is really just general supportive care, so if you go about managing the patient, is doesn't really matter whether their SIRS is from sepsis or another cause.
Personally, I don't think ABX is appropriate or necessary in the field in most cases. Unless you have very long transports, in which case labs and ABX might be beneficial.
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Ewok Jerky
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As far as I know, we still shoot for broad spectrum ABX within an hour.
Best practice is to draw cultures before ABX, the exception is suspected bacterial meningitis where lumbar puncture is delayed (not sepsis).
Best practice is to draw cultures before ABX, the exception is suspected bacterial meningitis where lumbar puncture is delayed (not sepsis).
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I was wrong.
The Surviving Sepsis campaign still calls for ABX within an hour of recognition of severe sepsis or septic shock: Surviving Sepsis Campaign Guidelines
The Surviving Sepsis campaign still calls for ABX within an hour of recognition of severe sepsis or septic shock: Surviving Sepsis Campaign Guidelines
blindsideflank
Forum Lieutenant
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It states 3 hours here
http://www.survivingsepsis.org/Bundles/Documents/SSC_Bundle.pdf
But that doesn't mean one hour isn't better. Where's you see one hour? I know it is the goal in our hospital but not sure where they got that from.
This is also a great document for answering a lot of the questions here.
http://www.survivingsepsis.org/SiteCollectionDocuments/Bundle-3-Hour-Sepsis-Step2-Blood-Cultures.pdf
2. Obtain Blood Cultures Prior to Administration of Antibiotics
Related Measures
Timing of Blood Cultures
Background
The incidence of sepsis and bacteremia in critically ill patients has been increasing in the past two decades.[8,9] Thirty percent to 50 percent of patients presenting with a clinical syndrome of severe sepsis or shock have positive blood cultures. Therefore, blood should be obtained for culture in any critically ill septic patient.
Collecting blood cultures prior to antibiotic administration offers the best hope of identifying the organism that caused severe sepsis in an individual patient. Failure to check blood cultures prior to antibiotic infusion will perhaps affect the growth of any blood borne bacteria and prevent a culture from becoming positive later.
Collection Strategy
Two or more blood cultures are recommended with at least one drawn percutaneously
and one drawn through each vascular access device, unless the device was recently
inserted (<48 hours).[1,2] In patients with suspected catheter-related infection, a pair of
blood cultures obtained through the catheter hub and a peripheral site should be obtained simultaneously. Cultures of other sites (preferably quantitative, where appropriate), such as urine, cerebrospinal fluid, wounds, respiratory secretions, or other body fluids that may be
the source of infection should also be obtained before antimicrobial therapy.[2] If the same organism is recovered from both cultures, the likelihood that the organism is causing the severe sepsis is enhanced. In addition, if the culture drawn through the vascular access device is positive much earlier than the peripheral blood culture (i.e., >2 hours earlier), it may offer support that the vascular access device is the source of the infection.[3] Volume of blood may also be important.[4]
Indications
Fever, chills, hypothermia, leukocytosis, left shift of neutrophils, neutropenia, and the development of otherwise unexplained organ dysfunction (e.g., renal failure or signs of hemodynamic compromise) are specific indications for obtaining blood for culture. Blood cultures should be taken as soon as possible after the onset of fever or chills.
While it remains difficult to predict bacteremia in patients with sepsis[5], a number of clinical and laboratory parameters are independently correlated with the presence of bacteria in the blood of patients when infection is suspected. These include chills, hypoalbuminemia, the development of renal failure, and a diagnosis of urinary tract infection[5,6]; other criteria are new fever, hypothermia, leukocytosis and left shift of neutrophils, neutropenia, and signs of hemodynamic compromise.[7] Peaking fever appears to be more sensitive than leukocytosis to predict bacteremia[8]; however, fever and low-grade bacteremia can be continuous, such as in endocarditis.
Grading the Evidence
The 2012 Surviving Sepsis Campaign Guidelines recommend obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay in antibiotic administration.
Evidence Grade 1C: This is a strong recommendation for care based on a number of qualitative considerations. The quality of the evidence generally derives from well-done observational or cohort studies with controls.
Tips
1. Create a standardized protocol to manage severe sepsis that includes reminders to draw blood cultures before administering antibiotics.
2. Place prompts in locations near antibiotic storage querying staff regarding whether blood cultures have been drawn.
3. Store first dose antibiotics in automated dispensing system on unit.
http://www.survivingsepsis.org/Bundles/Documents/SSC_Bundle.pdf
But that doesn't mean one hour isn't better. Where's you see one hour? I know it is the goal in our hospital but not sure where they got that from.
This is also a great document for answering a lot of the questions here.
http://www.survivingsepsis.org/SiteCollectionDocuments/Bundle-3-Hour-Sepsis-Step2-Blood-Cultures.pdf
2. Obtain Blood Cultures Prior to Administration of Antibiotics
Related Measures
Timing of Blood Cultures
Background
The incidence of sepsis and bacteremia in critically ill patients has been increasing in the past two decades.[8,9] Thirty percent to 50 percent of patients presenting with a clinical syndrome of severe sepsis or shock have positive blood cultures. Therefore, blood should be obtained for culture in any critically ill septic patient.
Collecting blood cultures prior to antibiotic administration offers the best hope of identifying the organism that caused severe sepsis in an individual patient. Failure to check blood cultures prior to antibiotic infusion will perhaps affect the growth of any blood borne bacteria and prevent a culture from becoming positive later.
Collection Strategy
Two or more blood cultures are recommended with at least one drawn percutaneously
and one drawn through each vascular access device, unless the device was recently
inserted (<48 hours).[1,2] In patients with suspected catheter-related infection, a pair of
blood cultures obtained through the catheter hub and a peripheral site should be obtained simultaneously. Cultures of other sites (preferably quantitative, where appropriate), such as urine, cerebrospinal fluid, wounds, respiratory secretions, or other body fluids that may be
the source of infection should also be obtained before antimicrobial therapy.[2] If the same organism is recovered from both cultures, the likelihood that the organism is causing the severe sepsis is enhanced. In addition, if the culture drawn through the vascular access device is positive much earlier than the peripheral blood culture (i.e., >2 hours earlier), it may offer support that the vascular access device is the source of the infection.[3] Volume of blood may also be important.[4]
Indications
Fever, chills, hypothermia, leukocytosis, left shift of neutrophils, neutropenia, and the development of otherwise unexplained organ dysfunction (e.g., renal failure or signs of hemodynamic compromise) are specific indications for obtaining blood for culture. Blood cultures should be taken as soon as possible after the onset of fever or chills.
While it remains difficult to predict bacteremia in patients with sepsis[5], a number of clinical and laboratory parameters are independently correlated with the presence of bacteria in the blood of patients when infection is suspected. These include chills, hypoalbuminemia, the development of renal failure, and a diagnosis of urinary tract infection[5,6]; other criteria are new fever, hypothermia, leukocytosis and left shift of neutrophils, neutropenia, and signs of hemodynamic compromise.[7] Peaking fever appears to be more sensitive than leukocytosis to predict bacteremia[8]; however, fever and low-grade bacteremia can be continuous, such as in endocarditis.
Grading the Evidence
The 2012 Surviving Sepsis Campaign Guidelines recommend obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay in antibiotic administration.
Evidence Grade 1C: This is a strong recommendation for care based on a number of qualitative considerations. The quality of the evidence generally derives from well-done observational or cohort studies with controls.
Tips
1. Create a standardized protocol to manage severe sepsis that includes reminders to draw blood cultures before administering antibiotics.
2. Place prompts in locations near antibiotic storage querying staff regarding whether blood cultures have been drawn.
3. Store first dose antibiotics in automated dispensing system on unit.
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blindsideflank
Forum Lieutenant
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The reasons for lactate (indicate hypoperfusion despite normotensive pt)
http://www.survivingsepsis.org/SiteCollectionDocuments/Bundle-3-Hour-Step1-Measure-Lactate.pdf
3. Administer Broad Spectrum Antibiotics
http://www.survivingsepsis.org/SiteCollectionDocuments/Bundle-3-Hour-Sepsis-Step3-Antibiotics.pdf
4. Administer 30 mL/kg Crystalloid
for Hypotension or Lactate ≥4 mmol/L
http://www.survivingsepsis.org/SiteCollectionDocuments/Bundle-3-Hour-Step4-Fluids.pdf
http://www.survivingsepsis.org/SiteCollectionDocuments/Bundle-3-Hour-Step1-Measure-Lactate.pdf
3. Administer Broad Spectrum Antibiotics
http://www.survivingsepsis.org/SiteCollectionDocuments/Bundle-3-Hour-Sepsis-Step3-Antibiotics.pdf
4. Administer 30 mL/kg Crystalloid
for Hypotension or Lactate ≥4 mmol/L
http://www.survivingsepsis.org/SiteCollectionDocuments/Bundle-3-Hour-Step4-Fluids.pdf