Which antibiotics are used in the treatment of sepsis/septic shock?

Updated: Oct 07, 2020
  • Author: Andre Kalil, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Answer

The selection of appropriate agents is based on the patient’s underlying host defenses, the potential sources of infection, and the most likely culprit organisms. Antibiotics must be broad-spectrum agents and must cover gram-positive, gram-negative, and anaerobic bacteria because organisms from any of these different classes can produce the same clinical picture of distributive shock.

If the patient is “antibiotic-experienced,” strong consideration should be given to using an aminoglycoside rather than a quinolone or cephalosporin for gram-negative coverage. Knowing the antibiotic resistance patterns of both the hospital itself and its referral base (ie, nursing homes) is very important.

Antibiotics should be administered parenterally, in doses adequate to achieve bactericidal serum levels. Many studies have found that clinical improvement correlates with the achievement of serum bactericidal levels rather than with the number of antibiotics given.

In the selection of empiric antibiotics, the increasing prevalence of MRSA must be taken into account, and an agent such as vancomycin or linezolid should be included. This is especially true in patients with a history of IV drug use, those with indwelling vascular catheters or devices, or those with recent hospitalizations. Antianaerobic coverage is indicated in patients with intra-abdominal or perineal infections.

Certain organisms, chiefly Enterobacteriaceae (eg, Escherichia coli and Klebsiella pneumoniae), contain a beta-lactamase enzyme that hydrolyzes the beta-lactam ring of penicillins and cephalosporins and thus inactivates these antibiotics (ESBL-producing bacteria). This phenomenon has become an increasing concern as its prevalence has increased. Beta-lactam antibiotics that have remained effective against ESBL-producing organisms include cephamycins (eg, cefotetan) and carbapenems (eg, imipenem, meropenem, and ertapenem). [94]

In immunocompetent patients, monotherapy with carbapenems (eg, imipenem and meropenem), third- or fourth-generation cephalosporins (eg, cefotaxime, cefoperazone, ceftazidime, and cefepime), or extended-spectrum penicillins (eg, ticarcillin and piperacillin) is usually adequate, without the need for a nephrotoxic aminoglycoside. [95] Patients who are immunocompromised or at high risk for multidrug-resistant organisms typically require dual broad-spectrum antibiotics with overlapping coverage.

Within these general guidelines, no single combination of antibiotics is clearly superior to any other.


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