Quality statement 3 – Management of antimicrobial therapy

A patient with suspected sepsis has blood cultures taken immediately, ensuring that this does not delay the administration of appropriate antimicrobial therapy. When signs of infection-related organ dysfunction are present, appropriate antimicrobials are started within 60 minutes. Antimicrobial therapy is managed in line with the Antimicrobial Stewardship Clinical Care Standard, including a review within 48 hours from the first dose.

Purpose

To ensure access to timely and appropriate antimicrobial treatment for patients with sepsis.

For patients

If you or a family member has sepsis, it is important that the infection is treated quickly. This will usually mean giving an antimicrobial medicine, usually an antibiotic (see Figure 2). When you are very sick, these medicines must be started within 60 minutes from when sepsis is identified.

Figure 2: What are antimicrobials?

You will need tests (usually a blood test called a blood culture) that will help your doctors make sure they are using the best medicine for you. Usually, the tests will be done and then you will start treatment while you are waiting for the results. However, this is not always possible and the tests may be taken later.

The first antimicrobials you receive will treat a wide range of infections because sepsis is an emergency. In the first few days, more information may become available about your infection and the antimicrobials may be changed to target your infection more specifically. For example, your antimicrobial may be changed to a different antimicrobial, or from an injection to a tablet, especially within the first two days. It is important to use the best medicines for your infection, and your doctor will decide this based on your needs. You may need more tests, such as blood and urine tests, to:

  • Find out if the treatment is working
  • Make sure you are receiving the most effective antimicrobial. 

For clinicians

Obtain blood cultures for microbiological testing for patients with suspected sepsis before administering antimicrobials, where this does not delay urgent treatment. For adults, this includes two sets of blood cultures, and for children one set of blood cultures. Other relevant microbiological cultures should also be collected, ideally before administering antimicrobials. In the community setting, if this is outside the scope of clinical practice, refer the patient to hospital immediately.

Do not wait for blood test results if someone is clearly unwell. Urgent antimicrobial therapy should start as soon as possible. Do not withhold antimicrobials while awaiting the results of microbiological (for example, blood, urine, pus, sputum microscopy or culture) or other tests.

Start antimicrobials within 60 minutes of recognising infection-related organ dysfunction, and as soon as possible if shock is present. In an adult patient without shock, where there is uncertainty about the likelihood of an infectious cause, rapidly investigate alternative diagnoses. Escalate care to a clinician with experience in recognising and managing sepsis, if required. If concern for infection persists after appropriate evaluation, start antimicrobial therapy as soon as possible, no later than three hours from initial clinical review (Figure 1). Closely monitor all patients who may have sepsis and ensure their care is escalated in the event of deterioration, such as evolving or worsening signs of organ dysfunction (refer to Quality statement 2 – Time-critical management).

Arrange consultation with an infectious diseases physician or clinical microbiologist if there is uncertainty about the appropriate antimicrobial therapy or local sepsis guidelines, ideally when initiating therapy, or else on review. As patients with sepsis often require higher doses of antimicrobials, the patient’s other medicines should be reviewed by an experienced clinician, preferably a pharmacist, to avoid interactions and enable the safe and appropriate administration of antimicrobial therapy.

When prescribing antimicrobials for Aboriginal or Torres Strait Islander peoples, consider the higher prevalence of multidrug-resistant organisms. Refer to the Central Australian Rural Practitioners Association guidelines, or other guidelines based on local resistance data, where appropriate.

If the patient with sepsis is being transferred to another healthcare service or unit, take blood cultures and start the first dose of antimicrobials before transfer.

Prompt communication of critical test results is essential to inform timely antimicrobial treatment decisions. If microbiological tests are ordered, review the results as soon as available and at least daily while concerns about sepsis persist. Use this information to consider whether review, adjustment or cessation of antimicrobials and other therapy is needed. Investigate and manage the source of infection, which may require surgery. Multidisciplinary input may be needed to choose appropriate investigations for the suspected infection.

Laboratories or microbiologists should call positive blood culture results through to the doctor caring for the patient as soon as these results are available, and document the discussion.

For healthcare services

Ensure that patients with suspected sepsis will be assigned an adequate triage category when presenting to a hospital emergency department to allow timely antimicrobial administration.

Ensure that systems and resources are in place for the appropriate collection of blood cultures. Ensure prompt communication of critical test results, including positive blood cultures, from laboratories directly to the clinician to inform timely antimicrobial treatment decisions. Establish clear referral procedures to allow access to infectious diseases and microbiology consultation. Embedding alert systems and flags in local clinical information systems may be a viable option.

Ensure that systems are in place to allow prompt administration of appropriate antimicrobials for the treatment of sepsis, in any location where people with sepsis may present for acute treatment. Review antimicrobial formularies regularly to ensure they support best-practice prescribing. Ensure 24-hour access to antimicrobials that are required urgently as part of the sepsis clinical pathway.

Evaluate antimicrobial use and prescribing in line with the National Safety and Quality Health Service Preventing and Controlling Infections Standard Actions 3.18 and 3.19. Ensure that effective antimicrobial stewardship systems are in place to ensure appropriate antimicrobial treatment and that service provision aligns with the Antimicrobial Stewardship Clinical Care Standard (Box 2 below).

Support multidisciplinary collaboration between critical care, medical and surgical teams to optimise the timely management of patients.

Box 2: Align sepsis management with the Antimicrobial Stewardship Clinical Care Standard

Sepsis management should align with the Antimicrobial Stewardship Clinical Care Standard, including:

  • Prescribing in line with the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines and the antimicrobial formulary. Ensure that the empirical and ongoing antimicrobial treatment are appropriate for the suspected site and nature of the infection, local antimicrobial resistance patterns, age and weight of the patient. This includes the antimicrobial agent, dose, route and frequency of administration
  • Appropriate sampling for microbiology testing and review, including testing for the suspected source of the infection and prompt review to ensure that the results inform ongoing antimicrobial therapy
  • Documenting the antimicrobial and the intended duration or review plan in the patient’s healthcare record
  • Reviewing therapy 24–48 hours after the first dose, including reviewing the need for ongoing antimicrobial use, microbial spectrum of activity, dose, frequency and route of administration and adjusting these accordingly.

For patients

If you or a family member has sepsis, it is important that the infection is treated quickly. This will usually mean giving an antimicrobial medicine, usually an antibiotic (see Figure 2). When you are very sick, these medicines must be started within 60 minutes from when sepsis is identified.

Figure 2: What are antimicrobials?

You will need tests (usually a blood test called a blood culture) that will help your doctors make sure they are using the best medicine for you. Usually, the tests will be done and then you will start treatment while you are waiting for the results. However, this is not always possible and the tests may be taken later.

The first antimicrobials you receive will treat a wide range of infections because sepsis is an emergency. In the first few days, more information may become available about your infection and the antimicrobials may be changed to target your infection more specifically. For example, your antimicrobial may be changed to a different antimicrobial, or from an injection to a tablet, especially within the first two days. It is important to use the best medicines for your infection, and your doctor will decide this based on your needs. You may need more tests, such as blood and urine tests, to:

  • Find out if the treatment is working
  • Make sure you are receiving the most effective antimicrobial. 

For clinicians

Obtain blood cultures for microbiological testing for patients with suspected sepsis before administering antimicrobials, where this does not delay urgent treatment. For adults, this includes two sets of blood cultures, and for children one set of blood cultures. Other relevant microbiological cultures should also be collected, ideally before administering antimicrobials. In the community setting, if this is outside the scope of clinical practice, refer the patient to hospital immediately.

Do not wait for blood test results if someone is clearly unwell. Urgent antimicrobial therapy should start as soon as possible. Do not withhold antimicrobials while awaiting the results of microbiological (for example, blood, urine, pus, sputum microscopy or culture) or other tests.

Start antimicrobials within 60 minutes of recognising infection-related organ dysfunction, and as soon as possible if shock is present. In an adult patient without shock, where there is uncertainty about the likelihood of an infectious cause, rapidly investigate alternative diagnoses. Escalate care to a clinician with experience in recognising and managing sepsis, if required. If concern for infection persists after appropriate evaluation, start antimicrobial therapy as soon as possible, no later than three hours from initial clinical review (Figure 1). Closely monitor all patients who may have sepsis and ensure their care is escalated in the event of deterioration, such as evolving or worsening signs of organ dysfunction (refer to Quality statement 2 – Time-critical management).

Arrange consultation with an infectious diseases physician or clinical microbiologist if there is uncertainty about the appropriate antimicrobial therapy or local sepsis guidelines, ideally when initiating therapy, or else on review. As patients with sepsis often require higher doses of antimicrobials, the patient’s other medicines should be reviewed by an experienced clinician, preferably a pharmacist, to avoid interactions and enable the safe and appropriate administration of antimicrobial therapy.

When prescribing antimicrobials for Aboriginal or Torres Strait Islander peoples, consider the higher prevalence of multidrug-resistant organisms. Refer to the Central Australian Rural Practitioners Association guidelines, or other guidelines based on local resistance data, where appropriate.

If the patient with sepsis is being transferred to another healthcare service or unit, take blood cultures and start the first dose of antimicrobials before transfer.

Prompt communication of critical test results is essential to inform timely antimicrobial treatment decisions. If microbiological tests are ordered, review the results as soon as available and at least daily while concerns about sepsis persist. Use this information to consider whether review, adjustment or cessation of antimicrobials and other therapy is needed. Investigate and manage the source of infection, which may require surgery. Multidisciplinary input may be needed to choose appropriate investigations for the suspected infection.

Laboratories or microbiologists should call positive blood culture results through to the doctor caring for the patient as soon as these results are available, and document the discussion.

For healthcare services

Ensure that patients with suspected sepsis will be assigned an adequate triage category when presenting to a hospital emergency department to allow timely antimicrobial administration.

Ensure that systems and resources are in place for the appropriate collection of blood cultures. Ensure prompt communication of critical test results, including positive blood cultures, from laboratories directly to the clinician to inform timely antimicrobial treatment decisions. Establish clear referral procedures to allow access to infectious diseases and microbiology consultation. Embedding alert systems and flags in local clinical information systems may be a viable option.

Ensure that systems are in place to allow prompt administration of appropriate antimicrobials for the treatment of sepsis, in any location where people with sepsis may present for acute treatment. Review antimicrobial formularies regularly to ensure they support best-practice prescribing. Ensure 24-hour access to antimicrobials that are required urgently as part of the sepsis clinical pathway.

Evaluate antimicrobial use and prescribing in line with the National Safety and Quality Health Service Preventing and Controlling Infections Standard Actions 3.18 and 3.19. Ensure that effective antimicrobial stewardship systems are in place to ensure appropriate antimicrobial treatment and that service provision aligns with the Antimicrobial Stewardship Clinical Care Standard (Box 2 below).

Support multidisciplinary collaboration between critical care, medical and surgical teams to optimise the timely management of patients.

Box 2: Align sepsis management with the Antimicrobial Stewardship Clinical Care Standard

Sepsis management should align with the Antimicrobial Stewardship Clinical Care Standard, including:

  • Prescribing in line with the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines and the antimicrobial formulary. Ensure that the empirical and ongoing antimicrobial treatment are appropriate for the suspected site and nature of the infection, local antimicrobial resistance patterns, age and weight of the patient. This includes the antimicrobial agent, dose, route and frequency of administration
  • Appropriate sampling for microbiology testing and review, including testing for the suspected source of the infection and prompt review to ensure that the results inform ongoing antimicrobial therapy
  • Documenting the antimicrobial and the intended duration or review plan in the patient’s healthcare record
  • Reviewing therapy 24–48 hours after the first dose, including reviewing the need for ongoing antimicrobial use, microbial spectrum of activity, dose, frequency and route of administration and adjusting these accordingly.

Resources

Related resources have been identified which are relevant to the quality statements, including:

  • Decision support tools and sepsis pathways and other guidance about sepsis - including state and territory resources
  • Guidelines and tools for recognising and responding to acute deterioration, including patient escalation pathways for each state and territory
  • Resources to support management of antimicrobial therapy
  • Education and information for patients and carers during hospitalisation for sepsis, on discharge and through survivorship.

A range of implementation resources have also been developed by the Commission including guidance, factsheets and tools for healthcare services and clinicians ,and resources for consumers.