Canterbury DHB

Sepsis (Post-operative)

• Sepsis is a medical emergency – see Hospital HealthPathways.
• Vital signs provide useful clues. At least two of the following should be present:
  • Temperature > 38°C or < 36°C
  • Heart rate > 90 beats per minute
  • Respiratory rate > 20 breaths per minute or PaCO₂ < 32 mm Hg
  • WBC count > 12 x 10⁹/L or < 4 x 10⁹/L or the presence of immature neutrophils (toxic granulation).

  This is a useful starting point only and requires interpretation. In patients with signs of septic shock, early consultation with ICU is recommended.

• Diagnosis: take appropriate cultures, a minimum of 2 sets of blood cultures and urine cultures, and a culture of the site.

Post-abdominal surgery

cefuroxime HMLSchedNZFPMLnoids Cefuroxime F: 0.4 Half life: 2 hours Elimination: renal fe: 0.9

IV 1.5 g every eight hours

• fe = 0.9, consider adjusting dose if CrCl is reduced.

AND

gentamicin HMLSchedNZFPMLnoids Gentamicin F: n/a Half life: 3 hours Elimination: renal fe: 0.9 Additional points: TDM.

IV 5 to 7 mg/kg ideal body weight initially, then see dosing guidelines.

• fe = 0.9, adjust dose if CrCl reduced.

AND

metronidazole HMLSchedNZFPMLnoids Metronidazole F: 1 Half life: 8 hours Elimination: oxidation, glucuronidation fe: 0.1

IV 500 mg every twelve hours

• High oral availability – prescribe orally unless GI absorption is compromised or patient is nil by mouth.
• Metabolised by unknown pathways. (fe = 0.1).

Severe penicillin allergy – consult with Infectious Diseases/Clinical Microbiology

If multi-drug resistant organism isolated or suspected give

piperacillin+tazobactam HMLNZFPMLnoids Piperacillin+Tazobactam F: n/a Half life: 1 hour Elimination: renal fe: 0.8/0.6 (Tazocin™)

IV 4 g/500 mg every six hours

• If still on piperacillin+tazobactam beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
• fe (piperacillin) = 0.8, fe (tazobactam) = 0.6, consider adjusting dose if CrCl reduced.

OR

meropenem HMLNZFPMLnoids Meropenem F: n/a Half life: 1 hour Elimination: renal; hydrolysis fe: 0.7

IV 1 g every eight hours

• Meropenem rapidly and significantly reduces sodium valproate concentrations. Concomitant administration may precipitate seizures in patients with a pre-existing seizure disorder. Discuss alternative antibiotic options with Infectious Diseases/Clinical Microbiology.
• If still on meropenem beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
• fe = 0.7, start with full dose initially then consider extending dose interval and/or decreasing dose for subsequent doses if CrCl is reduced (< 30 mL/min). Consult pharmacist.

Post-orthopaedic surgery

flucloxacillin HMLSchedNZFPMLnoids Flucloxacillin F: 0.9 Half life: 1 hour Elimination: renal fe: 0.7

IV 2 g every six hours

• fe = 0.7, consider adjusting dose if CrCl reduced.
• Risk of hepatotoxicity is increased in females, patients > 55 years old, high doses, and courses longer than 14 days duration.

PLUS

• fe = 0.9, adjust dose if CrCl reduced.

Mild penicillin allergy

cefazolin HMLSchedNZFPMLnoids Cefazolin F: n/a Half life: 2 hours Elimination: renal fe: 0.9

IV 2 g every eight hours

• fe = 0.9, consider adjusting dose if CrCl reduced.

PLUS

• fe = 0.9, adjust dose if CrCl reduced.

must be prescribed or recommended by a consultant.

Topic Code: 99283