Severe Sepsis / Septic Shock Antibiotic and Fluid Order Form

Severe Sepsis / Septic Shock Antibiotic and Fluid Order Form (page 1 of 3)Date:MRN:Name:Date of Birth:Physician to call all orders to pharmacy- Pharmacy Sepsis Phone 164708Critical Care Pharmacy 163611, Surgical ICU 160551 or 160552, Central Pharmacy 163324If ordering Tobramycin or VancomycinHeight: _________ Weight__________ Serum Creatinine_________Obtain the following labs and cultures: Blood (peripheral) x 2 sets Urine (and urinalysis) Mini Bronchoalveolar lavage(BAL) Stool for Clostridium Difficile toxin Other Cultures______________________________ Serum Lactate Venous Blood GasANTIBIOTIC THERAPY – START STATHealthcare Associated Pneumonia or Ventilator Associated Pneumonia or UnknownSource Vancomycin 25 mg/kg IVPB (rounded to the nearest 250 mg, maximum single dose is2000 mg ) = _______mg Start NOW and then pharmacy to dose. First dose must bespecified and then pharmacy to dose. (preferred agent)OR Linezolid (Zyvox) 600 mg every 12 hours IVPB. If Gram stain with GramSAMPLEpositive cocci in clusters, initial cultures positive for methicillin resistant staphylococcus aureus (MRSA),patient with a recent history of MRSA, or non-response to vancomycin (MRSA cultures positive withevidence of ongoing infection at 72 hours), linezolid may be started as primary therapy.AND Cefepime 2 grams IVPB NOW and every 8 hours (preferred agent)OR Aztreonam (Azactam) 2 grams IVPB NOW and every 8 hours IVPB if documented- penicillin (anaphylaxis)and cephalosporin allergy (if only a rash to penicillin, can use cefepime)OR Piperacillin / Tazobactam (Zosyn) 4.5 grams IVPB NOW and every 6 hours IVPB. If documented orsuspected Gram negative organisms resistant to cefepime or suspected aspiration (ICU only)With or Without Tobramycin 3 mg/kg IVPB for 1 dose NOW, dose = _______ mg. First dose must be specified, then pharmacyto dose (Tobramycin is optional treatment, may delete if low risk of a resistant organism or high risk of renal failure)Community Acquired Pneumonia Azithromycin 500 mg IVPB NOW and every 24 hoursAND Ceftriaxone 1 gram IVPB NOW and every 24 hoursWith or Without (for suspected community acquired MRSA) Vancomycin 25 mg/kg IVPB (rounded to the nearest 250 mg, maximum single dose is 2000 mg ) = _______mgStart NOW and then pharmacy to dose. First dose must be specified and then pharmacy to dose. (preferred agent)OR Linezolid (Zyvox) 600 mg every 12 hours IVPB. Per criteria aboveORIf documented penicillin (anaphylaxis) or cephalosporin allergy (if only a rash to penicillin, can use ceftriaxone) Moxifloxacin 400 mg IVPB NOW and every 24 hoursAND Aztreonam (Azactam) 2 grams IVPB NOW and every 8 hoursWith or Without (for suspected community acquired MRSA) Vancomycin 25 mg/kg IVPB (rounded to the nearest 250 mg, maximum single dose is 2000 mg ) = _______mgStart NOW and then pharmacy to dose. First dose must be specified and then pharmacy to dose. (preferred agent)OR Linezolid (Zyvox) 600 mg every 12 hours IVPB. Per criteria aboveHFH-86-0693MR-0311