From: Development of quality indicators for antimicrobial treatment in adults with sepsis
Quality indicators | Level of supporting evidence (see Table2) | First questionnaire | Consensus meeting | Second questionnaire | ||||
---|---|---|---|---|---|---|---|---|
 |  | Median score | % in highest tertile | Conclusion |  | Nr of experts prioritizing the QI | Total score | Conclusion |
1. Start antimicrobial therapy intravenously in adult patients with sepsis | 4 | 9 | 92 | Accepteda | Accepted | 7 | 26 | Accepted |
2. Start antimicrobial therapy as soon as possible, preferably within the first hour in adult patients with severe sepsis and septic shock | 2 | 9 | 100 | Accepted | Accepted | 12 | 50 | Accepted |
3. Before starting antimicrobial therapy, at least two sets of blood cultures, and specimens for culture from suspected sites of infection should be taken. | 4 | 9 | 100 | Accepted | Accepted | 9 | 36 | Accepted |
4. For community-acquired sepsis without neutropenia and without an obvious site of infection, start a second or third generation cephalosporin, or amoxicillin and clavulanic acid + an aminoglycoside. Duration of therapy: 7–10 days. | * | 8 | 92 | Accepted | Mergedd into number 43/44 |  |  |  |
5. For nosocomial sepsis without neutropenia and with no obvious site of infection, start piperacillin with tazobactam, or a second or third generation cephalosporin (except ceftazidime) in combination with either an aminoglycoside or an anti-pseudomonal fluoroquinolone. Duration of therapy: 7–10 days. | * | 7 | 75 | Discussionb | Merged into number 43/44 |  |  |  |
6. For community-acquired or nosocomial sepsis with neutropenia and without an obvious site of infection, start piperacillin and tazobactam +/− an aminoglycoside or a carbapenem with anti-pseudomonal activity (imipenem/meropenem) as empirical antibacterial regimen. Duration of therapy: 7–10 days. | * | 7 | 75 | Discussion | Merged into number 43/44 |  |  |  |
7. The addition of an aminoglycoside to a beta-lactam agent in adult patients with sepsis is not recommended, unless based on local resistance data and epidemiology (e.g. risk factors for ESBL) a broad spectrum of empirical therapy against Gram-negative pathogens is needed. | * | 8 | 75 | Accepted | Accepted | 3 | 6 | Rejected |
8. Glycopeptides should generally not be part of the empirical antibacterial regimen in adults with sepsis (with or without neutropenia), unless patients are known to be colonised with MRSA, or in patients with severe sepsis and neutropenia who received penicillin or cephalosporin prophylaxis. | * | 8 | 83 | Accepted | Accepted | 0 | 0 | Rejected |
9. For community-acquired and nosocomial sepsis and prior use of cephalosporins or quinolones within 30Â days before presentation, an aminoglycoside should be added or a carbapenem with antipseudomonal activity should be started. This also accounts for adults colonised with ESBL-producing micro-organisms and for those admitted to a hospital with high prevalence of ESBL-producing Enterobacteriaceae. If prevalence is unknown, risk factors for ESBL should be used. Risk factors are: a nosocomial infection, prior use of antibiotics and presence of an indwelling urinary catheter. | 2 | 8 | 92 | Accepted | Accepted | 2 | 4 | Rejected |
10. Empirical antifungal therapy may be considered in selected cases: unexplained sepsis with long-term ICU stay, significant Candida colonisation, and clinical risk factors such as abdominal surgery, anastomosis leakage, the presence of a central venous catheter and the use of broad spectrum antibiotics. | * | 8 | 73 | Accepted | Merged into number 43/44 | Â | Â | Â |
11. For sepsis with a hospital-acquired pneumonia or a ventilated-acquired pneumonia, start amoxicillin and clavulanic acid + an aminoglycoside or ciprofloxacin, or the combination of a second/third generation cephalosporin (excluding ceftazidime) with an aminoglycoside or ciprofloxacin or start piperacillin with tazobactam. Duration of therapy: maximum of 8 days. | 1 | 7 | 67 | Rejectedc |  |  |  |  |
12. For urosepsis, start a second/third generation cephalosporin or the combination of amoxicillin and gentamicin as empirical antibacterial regimen. Duration of therapy: 10Â days. | * | 7 | 92 | Discussion | Merged into number 43/44 | Â | Â | Â |
13. For urosepsis and an indwelling urinary catheter, start a second/third generation cephalosporin + an aminoglycoside or quinolone as empirical antibacterial regimen. | * | 7 | 67 | Rejected |  |  |  |  |
14. In adults with urosepsis, glycopeptides should be restricted to those septic patients with previously bacteriologically proven Enterococcus faecium urinary tract infections in which enterococci are suspected to be the causative pathogens. | * | 8 | 83 | Accepted | Merged into number 43d | Â | Â | Â |
15. For community-acquired intra-abdominal sepsis, start a second/third generation cephalosporin + metronidazole +/− an aminoglycoside or amoxicillin and clavulanic acid +/− an aminoglycoside. Duration of therapy: 5–7 days. | 2 | 8 | 92 | Accepted | Merged into number 43/44 |  |  |  |
16. For nosocomial intra-abdominal sepsis, start a second/third generation cephalosporin + metronidazole + an aminoglycoside or amoxicillin and clavulanic acid + an aminoglycoside or piperacillin with tazobactam +/− an aminoglycoside. Duration of therapy: 5–7 days. | 2 | 7 | 75 | Discussion | Merged into number 43/44 |  |  |  |
17. For community-acquired sepsis with cholangitis, start amoxicillin + an aminoglycoside or amoxicillin and clavulanic acid +/− an aminoglycoside. Duration of therapy: up to 3 days following adequate drainage. | * | 7 | 83 | Discussion | Merged into number 43/44 |  |  |  |
18. For nosocomial sepsis with cholangitis, start amoxicillin (with or without clavulanic acid) + an aminoglycoside. Duration of therapy: up to 3 days following adequate drainage. | * | 7 | 75 | Discussion | Merged into number 43/44 |  |  |  |
19. For uncomplicated skin and skin structure infections (SSSI) with sepsis, start flucloxacillin. | 2 | 8 | 82 | Accepted | Merged into number 43 | Â | Â | Â |
20. For community acquired complicated SSSI with sepsis, start amoxicillin and clavulanic acid. Duration of therapy: 7–10 days. | * | 8 | 67 | Discussion | Merged into number 43/44 |  |  |  |
21. For nosocomial complicated SSSI with sepsis, start amoxicillin and clavulanic acid + an aminoglycoside or piperacillin with tazobactam. Duration of therapy: 7–10 days. | * | 8 | 75 | Accepted | Merged into number 43/44 |  |  |  |
22. For community-acquired sepsis and necrotising fasciitis, start amoxicillin and clavulanic acid + clindamycin. | * | 6 | 50 | Rejected |  |  |  |  |
23. For nosocomial sepsis and necrotising fasciitis, start amoxicillin and clavulanic acid + an aminoglycoside + clindamycin or piperacilllin with tazobactam +/− an aminoglycoside + clindamycin. | * | 7 | 67 | Rejected |  |  |  |  |
24. Cephalosporins (+/−metronidazole) are suitable alternatives in patients with non-IgE mediated penicillin rash. | * | 7 | 67 | Rejected |  |  |  |  |
25. In type I IgE allergic reactions to penicillins, aztreonam or ciprofloxacin +/− an aminoglycoside in combination with vancomycin should be chosen. | * | 6 | 45 | Rejected |  |  |  |  |
26. Individualization of dosing using therapeutic drug monitoring should be used whenever possible in adults with sepsis. For aminoglycosides after 3Â days and for vancomycin after 5Â days. | 3 | 6 | 50 | Rejected | Â | Â | Â | Â |
27. When starting vancomycin therapy, at least one trough concentration (just before the fourth dose) should be determined and the concentration should be 15-20Â mg/l. | 3 | 7 | 50 | Rejected | Â | Â | Â | Â |
28. Frequent measuring of vancomycin trough concentrations is recommended in patients with an increased risk of toxicity or unstable kidney function and > 5 days of treatment. | 3 | 8 | 75 | Accepted | Rephrased to number 47 |  |  |  |
29. With proven Pseudomonas bacteraemia, combination therapy should not be prescribed. Duration of therapy is 7 – 10 days. | 2 | 7 | 70 | Discussion | Merged into number 44/45 |  |  |  |
30. For sepsis due to methicillin susceptible Staphylococcus aureus, start flucloxacillin. | 2 | 8 | 100 | Accepted | Accepted | 1 | 3 | Rejected |
31. Micro-organisms with MICs > 1 mg/l such as Pseudomonas aeruginosa or patients with neutropenia should have an intravenous ciprofloxacin dosage of 400 mg tid. | 4 | 8 | 100 | Accepted | Accepted | 0 | 0 | Rejected |
32. Treatment duration should be 14Â days for sepsis and pneumonia due to S. aureus. | 4 | 9 | 89 | Accepted | Merged into number 44 | Â | Â | Â |
33. Treatment duration should be 14–21 days for sepsis and pneumonia due to Legionella pneumophila, Mycoplasma pneumoniae or Chlamydia spp. | 4 | 8 | 90 | Accepted | Merged into number 44 |  |  |  |
34. Treatment duration should be 14Â days in an uncomplicated Staphylococcus aureus bacteraemia. | 4 | 9 | 91 | Accepted | Merged into number 44 | Â | Â | Â |
35. With S. aureus bacteraemia it is important to search for complications, this will determine the duration of therapy. Complications are: a secondary infection together with the S. aureus bacteraemia (like an endocarditis, infected prosthesis, arthritis, osteomyelitis, meningitis, fasciitis, spleen abscess) | 4 | 8 | 67 | Discussion | Accepted | 1 | 2 | Rejected |
36. Persistence of positive blood cultures for more than 72Â hours after starting antibiotics should be considered as complicated S. aureus bacteraemia. | 4 | 8 | 75 | Accepted | Accepted | 1 | 1 | Rejected |
37. With sepsis and Listeriosis, the duration of therapy should be 21Â days. | 4 | 7 | 67 | Rejected | Â | Â | Â | Â |
38. After clinical recovery and when the identity and susceptibility of the causative micro-organism has been determined, a switch to oral agents with high bioavailability should be made. | 2 | 8 | 91 | Accepted | Rephrased to number 48 | Â | Â | Â |
39. Empirical antimicrobial therapy for presumed sepsis should be discontinued in case of clinical improvement and a lack of clinical and microbiological evidence of infection. Maximum duration of therapy is 7Â days. | 4 | 8 | 83 | Accepted | Accepted | 2 | 5 | Rejected |
40. Discontinue broad spectrum antimicrobial therapy after 72Â hours of clinical stability in patients with persisting febrile neutropenia that show no clinical or microbiological evidence of infection. Oral antimicrobial prophylaxis against Gram-negative micro-organisms should be continued until resolution of neutropenia. | 2 | 9 | 91 | Accepted | Accepted | 2 | 2 | Rejected |
QIs added after first questionnaire: | Â | Â | Â | Â | Â | Â | Â | Â |
41. When starting treatment in adults with sepsis, dose and dosing interval of systemic antimicrobial therapy should be adapted to renal function. | 4 | Â | Â | Addede | Accepted | 3 | 4 | Rejected |
42. Concerning empirical therapy for adult patients with sepsis, local guidelines should correspond to the national guideline, but should deviate based on local resistance patterns. | 4 | Â | Â | Â | Added | 9 | 27 | Accepted and merged with number 43 |
43. Empirical antimicrobial therapy (only choice of antimicrobial agent) in all adult patients with sepsis should be prescribed according to the national guideline. | * | Â | Â | Â | Added | 2 | 7 | Accepted and merged with number 42 |
44. In all adult patients with sepsis starting antimicrobial therapy the duration of therapy should be prescribed according to the national guideline. | 4 | Â | Â | Â | Added | 3 | 4 | Rejected |
45. Change empirical antimicrobial therapy to pathogen-directed therapy if culture results become available. | 3 | Â | Â | Â | Added | 7 | 15 | Accepted |
46. Patients with a S. aureus bacteraemia should have a blood culture taken 48 – 72 hours after starting empirical antibiotic therapy. | 4 |  |  |  | Added | 0 | 0 | Rejected |
47. Therapeutic drug monitoring should be done if vancomycin or aminoglycosides are given > 48 hours, according to the local guideline. The vancomycin trough concentration should be 15-20 mg/l. |  |  |  |  | Result from rephrasing number 28 | 1 | 1 | Rejected |
48. After clinical recovery and when the identity and susceptibility of the causative micro-organism has been determined, a switch to oral agents with high bioavailability should be made. Exceptions are: S. aureus bacteraemia, liver abscess, empyema, endocarditis, meningitis and infected prosthetic material. | Â | Â | Â | Â | Result from rephrasing number 38 | 1 | 1 | Rejected |