OF COURSE NOT. Amoxicillin and comitrazole should not be used as empirical treatment for bacterial sepsis

In case of severe bacterial sepsis, or “only” bacterial sepsis, we should use an association of a third generation cephalosporin (larger activity against potential bacteria) with an aminoglycoside (8 mg/kg for Genta or Tobra, or 20 mg/kg for Amikacin) whatever the initial creatinine value. The second dose being adapted to the calculated clearance or, if possible to the residual level.

Amoxicillin should not be any more used as empirical treatment for bacterial sepsis, outcome being linked to the efficiency and the rapidness of the treatment. Comitrazole, whereas largely used three decades ago in Europe, could be used in case of susceptibility of the pathogen, TMP-SMX resistance having largely increased in recent years. According to its low cost, it could be proposed as the second line for pyelonephritis, but not as empiric agent.

ANY HOW, DO NOT FORGET:

Fluid replacement,

That IV antimicrobial treatment should be started within the three hours after the "clinical” diagnosis,

That aminoglycosides are bacteridal and thus rapidly efficient,

Daily antimicrobial reassessment, to lower the spectrum and the costs,

To discuss the usefulness of the aminoglycoside at day 3. Combination should not use more than 5 days, except for P Aeruginosa;

That duration of 7 to 10 days is usually sufficient in case of source control (lower costs, lower resistance emergence…..)

When choosing an empiric treatment of severe sepsis, one should look at the whole scenario:

1. Empiric therapy should be guided by local databases of bacterial sensitivities. In our hospital only imipenem, meropenem, ertapenem, vancomycin, teicoplanin, linezolid and tigeciclin continue to show a virtual absence of resistance. Neither amoxicillin nor TMP/SMZ are appropriate in our setting. If I should choose an empiric and aspecific regimen in my dept, I would recommend a combination of PIP/TAZO plus gentamycin.

2. Combination therapy seems to be logical when the patient is neutropenic, immunodeficient, or when a difficult microorganism is suspected. Consider therapy for capsulated microorganisms if splenectomy.

3. The provenience of the patient is important, especially if pneumonia is the suspected source of sepsis. Community-acquired pneumonia treatment is quite different from Healtcare-associated pneumonia.

4. In other instances debridment of infected tissue or abscess drainage is mandatory; percutaneous interventions should be preferred if possible.

In our ICU, we do not have nosocomial urosepsis. Our main nosocomial sepsis is ventilation acquired pneumonia, mainly due to P aeruginosa 95% sensitive to AMK and more than 90% to imipenem.,60% of them being sensitive to PIP/TAZO, Our empiric treatment is thus AMK/imipenem, time to obtain the bacterial sensitivities of the pathogens, all patients having BAL before institution of the treatment..

But , this concerns our Medical ICU patients. Surgical ICU may have more pathogens and more resistance, particularly in case of suspected and not documented sepsis treated with large empirical treatment. for many days...

Thank you all for your contributions.

Filippus,

The choice of an antibiotic depends on many factors, the principle factor being the causative agent. The second factor depends on the prevalence of drug resistance; for example, Methicillin should not be prescribed in when there is a geographic area with high-prevalence of MRSA. Likewise, empirical TX of a PTB suspect with Isoniazid and Rifampin should be discouraged when treating pts from countries with high prevalence of MDR-TB or XDR-TB.

Finally, the choice of an antibiotic should be guided by drug susceptibility tests (DSTs).

Thanks,

Ben