Recommendations of Task Force
Evaluation and Treatment of Nosocomial Sepsis
Chair: T. Cox, Pharm.D.
Members: Lakshmi Katikaneni, M.D.; Sarah Taylor, M.D.; Carlene Speaks, N.N.P.;
Joan Demarest, R.N.; (NNP Alternate: Ashley Klum, N.N.P.)
Charge: Develop guidelines (based on current evidence, best-practice guidelines,
and MUSC patterns of practice and infection) for:
 Indications for which a sepsis evaluation should be performed (scoring
system)
 Components of the sepsis evaluation
 Initial therapy and duration of therapy
Recommendations:
1. Nosocomial Sepsis
a. Definition: evaluation beyond 1st 72 hours of life excluding sepsis
associated with a known source (e.g. not NEC, omphalitis, etc.)
b. Indications for evaluation: Work group considered use of a scoring
system to identify infants requiring a late onset sepsis evaluation
based on clinical, laboratory, and risk factor criteria. Only one such
scoring system was found in the literature. The investigators who
developed this system recommend external validation of the scoring
system in individual units before implementation of its use (Mahieu
2000, 2002). Recommendation of the work group is to defer the use of
such a scoring system at this time in order not to delay
implementation of a late onset sepsis pathway
2. Evaluation
a. Cultures:
i. Cultures of blood
1. Minimum blood culture volume = 1 ml.
2. Minimum 2 blood cultures for each sepsis work-up
3. Sources
a. With central Line: One blood culture should be
obtained from all central lines (excluding UAC
and UVC) and one blood culture should be
obtained by peripheral stick
b. No central line: 2 peripheral blood cultures.
4. Consideration should be given to holding blood
cultures for fungus if patient birth weight < 1000 g,
there is evidence of thrombocytopenia, or history of
frequent or prolonged antibiotic use.
ii. Urine (catheter or suprapubic, not bagged)
iii. CSF (if patient able to tolerate procedure. If patient is too
unstable to tolerate procedure, a future attempt should be
made as soon as possible after patient has been stabilized.)
iv. All should be obtained prior to starting antimicrobial therapy.
Once a decision is made to initiate a sepsis evaluation,
cultures should be obtained and antibiotics started as soon as
possible. Unnecessary delays should be avoided. If cultures
These recommendations should be individualized for specific patients, as clinically indicated.
Printed: 16-Feb-16
Revised 6/28/2004
Confidential: SC Statutes 40-71-10 & 40-71-20 protect this document from “…discovery, subpoena or introduction into evidence in
any civil action…”
cannot be obtained within 2 hours after the initiation of a
sepsis evaluation, attending physician should be notified.
v. Nursing to document source of all cultures on laboratory forms
1. Blood = central or peripheral; catheter or stick
2. Urine = catheter or suprapubic
3. Choice of antimicrobial therapy
a. Use of any antimicrobial requires assessment for potential
contraindications to therapy prior to starting treatment
b. Hemodynamically unstable or central line in place > 10 days (Maki
2002)
i. Vancomycin + piperacillin/tazobactam
ii. “Hemodynamically unstable” defined as requiring fluid boluses
or vasopressors to maintain blood pressure
c. Hemodynamically stable and central line, if present, in place < 10
days
i. Nafcillin and gentamicin
d. Consider addition of antifungal therapy for patients with birth weight <
1,000 grams, thrombocytopenia, significant drop in platelet count from
previously known values, or history of frequent or prolonged antibiotic
use
e. All antimicrobials should be infused through central line if present.
Nursing should notify MD or NNP if drug compatibility issues preclude
this.
4. Analysis of culture results
a. We recommend that methods be developed to distinguish true
infection with coagulase negative staphylococci (CoNS) from
contaminated blood cultures. Potential options include colony counts
and species identification on all positive blood cultures for CoNS. The
Microbiology Laboratory is not currently set up to perform these
functions; however, there is the potential that they could be.
b. All cultures negative at 48 hours -> d/c antibiotics (antifungals may
be continued x 72 hours (Schelonka 2003) pending negative results)
c. All positive urine and CSF cultures should be treated based on
organism identification and susceptibility.
d. Positive blood cultures
i. Practitioner notified by Microbiology Laboratory of Gram Positive
organism
1. Change nafcillin to vancomycin pending definitive ID.
2. Repeat blood culture before changing antibiotics.
3. Final antibiotic therapy should be guided by organism
identification and susceptibility.
ii. Contaminant organisms requiring no further antibiotic therapy
1. Corynebacterium
2. Propionibacterium
3. Penicillium (Stoll 2002)
4. Diphtheroids were also included among contaminant
organisms in this reference; however, according to Dr.
Johnson some may be true pathogens.
iii. Culture positive for (other than contaminant organisms)
Follow recommendations on Table 1
These recommendations should be individualized for specific patients, as clinically indicated.
Printed: 16-Feb-16
Revised 6/28/2004
Confidential: SC Statutes 40-71-10 & 40-71-20 protect this document from “…discovery, subpoena or introduction into evidence in
any civil action…”
iv. Patients with positive central line cultures due to the following
organisms require immediate line removal:
1. S aureus (Benjamin 2001)
2. Gram-negative rods (Benjamin 2001)
3. Fungi – (IDSA guidelines)
These recommendations should be individualized for specific patients, as clinically indicated.
Printed: 16-Feb-16
Revised 6/28/2004
Confidential: SC Statutes 40-71-10 & 40-71-20 protect this document from “…discovery, subpoena or introduction into evidence in
any civil action…”
References:
Craft A, Finer N. Nosocomial coagulase negative staphylococcal (CoNS) catheterrelated sepsis in preterm infants: Definition, diagnosis, prophylaxis, and prevention. J
Perinatol. 2001; 21: 186-192.
Benjamin DK, Miller W, Garges H, et al. Bacteremia, central catheters, and neonates:
When to pull the line. Pediatrics. 2001; 107 (6): 1272-1276.
Horbar JD, Rogowski J, Plsek PE, et al. Collaborative quality improvement for neonatal
intensive care. Pediatrics. 2001; 107 (1): 14-22.
Mahieu LM, De Muynck AO, De Dooy JJ, et al. Prediction of nosocomial sepsis in
neonates by means of a computer-weighted bedside scoring system (NOSEP score).
Crit Care Med. 2000; 28 (6): 2026-2033.
Mahieu LM, De Dooy JJ, Cossey VR, et al. Internal and external validation of the
NOSEP prediction score for nosocomial sepsis in neonates. Crit Care Med. 2002; 30
(7): 1459-1466.
Mermel LA, Farr BM, Sheretz RJ, et al. Guidelines for the management of intravascular
catheter-related infections. CID. 2001; 32 (1 May): 1249-1272.
Rubin LG, Sanchez PJ, Siegal J, et al. Evaluation and treatment of neonates with
suspected late-onset sepsis: A survey of neonatologists’ practices. Pediatrics. 2002;
110 (4). URL: http://www.pediatrics.org/cgi/content/full/110/4/e42.
Schelonka RL, Moser SA. Time to positive culture results in neonatal candida
septicemia. J Pediatr. 2003; 142: 564-565.
Stoll BJ, Hansen N, Fanaroff AA, et al. Late-onset sepsis in very low birth weight
neonates: The experience of the NICHD Neonatal Research Network. Pediatrics.
2002; 110 (2): 285-291.
These recommendations should be individualized for specific patients, as clinically indicated.
Printed: 16-Feb-16
Revised 6/28/2004
Confidential: SC Statutes 40-71-10 & 40-71-20 protect this document from “…discovery, subpoena or introduction into evidence in
any civil action…”