UMEM Educational Pearls

Takeaways

The Centers for Medicare and Medicaid Services (CMS) require broad spectrum antibiotics to be administered within 3 hours of presentation of sepsis to be in compliance with the sepsis measure. 

 

Not only do the antibiotics that are chosen determine compliance with this measure, but the order in which antibiotics are given can also significantly affect compliance. 

 

According to CMS, for combination antibiotic therapy, both antibiotics must be started within the three hours following presentation; however, they do not need to be completely infused within this time frame. 

 

Combination therapy typically includes a monotherapy antibiotic (see list in detailed information below) plus vancomycin (daptomycin or linezolid could also be used). 

 

So which antibiotic should be given first? 

 

If a monotherapy antibiotic is given first within the 3 hours of presentation, then compliance for the sepsis measure is met.  These antibiotics cover a broader range of bacteria and are typically infused over ~30 minutes, which allows plenty of time for your second antibiotic to be initiated.  

 

If vancomycin is given first, compliance with this measure can become difficult. First, vancomycin has a narrower spectrum of activity and is not a monotherapy antibiotic. Second, vancomycin infusion rates range from 1 to 2 hours.  Given that antibiotics are usually given after sepsis is flagged, this infusion rate only gives a short period of time for the second antibiotic to be initiated. Thus, vancomycin should almost always be the second antibiotic infused. 

 

In addition, patients may also have limited intravenous access or antibiotics may not be compatible with resuscitation fluids.  All of these factors together must be considered when trying to gain compliance with this measure. 

 

Take-Home Point: 

Administer monotherapy antibiotics (e.g. piperacillin/tazobactam and cefepimeprior to administering vancomycin in your septic patients to improve compliance with the sepsis measure. 

 
 

 

In-Depth

Antibiotic Monotherapy Selection
  • Doripenem
  • Ertapenem
  • Imipenem/cilastatin
  • Meropenem
  • Cefotaxime
  • Ceftazidime
  • Ceftriaxone
  • Cefepime
  • Ceftaroline
  • Moxifloxacin
  • Gatifloxacin
  • Amoxicillin/clavulanate
  • Ampicillin/sulbactam
  • Piperacillin/tazobactam
  • Ticarcillin/clavulanate

 

References

Specifications Manual for National Hospital Inpatient Quality Measures v5.4. The Joint Commission. https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx. Updated December 29, 2017.  Accessed August 31, 2018.