What are the first medications to give to a patient with spiking fever and sepsis?

First Medications for a Patient with Spiking Fever and Sepsis

Intravenous broad-spectrum antimicrobials must be administered within the first hour of recognizing sepsis or septic shock. 1

Immediate Antimicrobial Therapy

• Administer effective IV antimicrobials within the first hour of recognition of sepsis (with or without shock) as this is the most critical intervention 1
• Each hour delay in antimicrobial administration increases mortality by approximately 8% 2
• Initial empiric therapy should include one or more drugs with activity against all likely pathogens (bacterial and/or fungal or viral) 1
• Obtain appropriate cultures (including at least two sets of blood cultures) before starting antibiotics, but do not delay antimicrobial therapy if obtaining cultures would cause substantial delay 1

Antimicrobial Selection Guidelines

For Community-Acquired Sepsis:

• Use broad-spectrum beta-lactam (extended-spectrum penicillin/beta-lactamase inhibitor or 3rd/4th generation cephalosporin) 1
  • Options include piperacillin-tazobactam 3 or cefepime 4

For Healthcare-Associated Sepsis:

• Consider coverage for resistant organisms based on local antibiograms 1, 2
• For suspected MRSA: Add vancomycin or linezolid 1
• For suspected Pseudomonas: Consider combination therapy with an extended-spectrum beta-lactam plus either an aminoglycoside or fluoroquinolone 1

Special Circumstances:

• For neutropenic patients: Use combination empirical therapy 1
• For suspected fungal infection: Consider echinocandin or fluconazole based on local patterns 1
• For suspected viral etiology: Initiate appropriate antiviral therapy as early as possible 1

Hemodynamic Support

• For patients with septic shock (persistent hypotension despite initial fluid challenge): 5
  • Begin norepinephrine (0.02-0.05 μg/kg/min) when diastolic blood pressure is critically low or after initial fluid resuscitation fails to restore blood pressure 5
  • Target a mean arterial pressure (MAP) of 65 mmHg 5
  • Consider adding vasopressin (up to 0.03 U/min) if hypotension persists despite norepinephrine at 0.1-0.2 μg/kg/min 5

Initial Fluid Resuscitation

• Administer crystalloids at 30 mL/kg within the first 3 hours for patients with sepsis-induced hypoperfusion 5
• Continue fluid administration as long as hemodynamic parameters improve 5

Optimization and De-escalation

• Reassess antimicrobial regimen daily for potential de-escalation 1
• Empiric combination therapy should not be administered for more than 3-5 days 1
• De-escalate to the most appropriate single therapy once susceptibility profile is known 1, 6
• Typical duration of therapy is 7-10 days, though longer courses may be needed in specific circumstances 1

Common Pitfalls to Avoid

• Delaying antimicrobial administration beyond one hour 1, 2
• Failing to obtain appropriate cultures before starting antibiotics 1
• Using inadequate dosing strategies that don't account for altered pharmacokinetics in sepsis 1, 6
• Continuing broad-spectrum antibiotics unnecessarily when a pathogen is identified 1, 7
• Relying solely on fluid resuscitation in profound shock 5
• Using low-dose dopamine for renal protection 5