[CK] Empirical antibiotics cellulitis, Severe sepsis.

[WORKUP]
 pneumonia on chest radiography, fluid collection on computed tomography of the abdomen.

Abdomen CT - possible even without contrast !
IMAGE = Cholecystitis -> stone = op. ===============> MAIN is USG.
(Not for this. but used for r/o other etiology)
(or if it's not urgent = than USG. )

IMAGE = pyelonephritis -> mostly not. severely(72hours = later on!)

IMAGE = diverticulitis ===========================> No GB, Kidney => than do this(Full contrast CT scan for diagnosis, possible surgical candidate !! ) 
(The authors' practice is to perform an abdominal CT scan with oral and intravenous (IV) contrast to establish the diagnosis of acute diverticulitis because it has a high sensitivity and specificity for acute diverticulitis and can exclude other causes of abdominal pain)

US= ECHO = Caridology(not urgent)
Brain CT = not meaningful, but possible(not urgent)
LP = possible for meningitis.

SO
only diverticulitis(even without diarrhea, tender abdomen) =======> CT scan with contrast (key to survive !) 

[ ABX]

SEPSIS worst = PNA => VANC ZOSYN + LEVAQUIN
SEPSIS mid = ABD => VANC ZOSYN
SEPSIS easy = UTI => ZOSYN(cefepime)


0. SEPSIS(Cellulitis)
= VANC+ZOSYN

1. Systemic ?? = IV and/or 2. h/o MRSA?? (or purulent = MRSA)
    Systemic MRSA = VANC (only this, cover str+MRSA)
    Systemic Non MRSA = Cefazolin IV or Ceftriaxon IV(1st or 3rd, cover str only)

    Non systemic MRSA = PO Bactrim, Clindamycin, Doxazosyn (will cover str + MRSA)
    Non systemic Non MRSA = PO Cephalexin(Keflex) - mostly. (will cover str only)


[SEPSIS PROTOCOL]

NS: 30 mL/kg (actual body weight) within 3 hours following presentation.
< 3 HRS

ABx: within 1 hour


VCU protocol
:

Definitions:

• Septic Shock:  Presence or likelihood of infective source plus systemic manifestations of inflammation (i.e. T > 38.3 C or < 36 C; HR > 90; Tachypnea; WBC > 12K or < 4K or > 10% bands) plus persistent sepsis-induced hypotension (SBP < 90 mmHg or MAP < 70 mmHg) despite adequate fluid resuscitation.
• Severe Sepsis: Sepsis plus sepsis-induced organ dysfunction (Sepsis-induced hypotension; lactate elevated above upper limit of normal; UOP < 0.5 mL/kg/hr for >2h despite adequate fluid resuscitation; ALI [P/F ratio < 250 in absence of pneumonia < 200 in presence of pneumonia]; Cr > 2.0 or Cr double from baseline; Bili > 2; PLT < 100K; coagulopathy [INR > 1.5]); new mental status change based on new RASS other than zero or tissue hypoperfusion (lactate ≥ 4 mmol/L or persistent hypotension after initial fluid challenge)

Initial Management:

• Sepsis-induced tissue hypoperfusion recognized: Prompt administration of crystalloid IVF (30 mL/kg or more if needed) aimed at normalizing patient’s serum lactate.
• Within the first 3 hours:  IVF -> LACTATE, ABx       
  • Measure serum lactate
  • Administer appropriate broad spectrum antimicrobials (Table 1) active against likely pathogen within the first hour (as mortality increases appreciably with each hour of delay in administering antimicrobials in septic shock). Helpful to directly communicate urgency to nursing staff in order to expedite prompt delivery of antimicrobials.
  • Obtain cultures prior to antimicrobial therapy if they don’t cause significant delay in antimicrobial therapy (> 45 mins)
    • Two sets of blood cultures (anaerobic and aerobic)
      • One percutaneously
      • One from vascular access device (unless placed within 48 hours)
  • Obtain urinalysis/ urine culture, sputum/ other respiratory culture and wound cultures depending on clinical scenario
  • Remove vascular access if suspected to be source of infection promptly after other vascular access established
  • 
    
  • Within the first six hours: AFTER 6 HOURS. 
    • Initiate vasopressors for persistent hypotension unresponsive to initial fluid resuscitation to maintain a MAP of ≥ 65
    • If persistent hypotension despite adequate fluid resuscitation or initial lactate ≥ 4
      • Re-measurement of serum lactate (goal of normalization)

Other Key Considerations:

• Prior culture results should be considered when selecting empiric antibiotics.
• If a patient becomes septic while on antibiotics consideration should be given to switching agents/ escalating therapy.
• The antibiotic regimen should be re-assessed daily and de-escalated when appropriate.
• qSOFA not included in current version of guideline pending wider adaptation of this metric