Medication Summary
No drugs of choice exist for systemic inflammatory response syndrome (SIRS). Medication prescriptions target specific diagnoses, preexisting comorbidities, and prophylaxis regimens for complications. No pharmacologic agents have been demonstrated to improve the outcome of SIRS.
Because of increasing bacterial resistance, when an infectious cause for SIRS is a concern but no specific infection has been diagnosed, broad-spectrum antibiotics should be administered. Therapy for methicillin-resistant Staphylococcus aureus (MRSA) should be considered, owing to the rising prevalence of MRSA in the community.
Insulin therapy (in patients with hyperglycemia) and steroids should also be considered in patients who meet criteria for SIRS.
Antibiotics, Other
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. The therapy should be guided by available practice guidelines and knowledge of the local antibiogram, as well as the patient's risk factors for resistant pathogens and allergies. The key is to stop antibiotics when infection is ruled out or narrow the antibiotic spectrum once a pathogen is found.
Cefepime (Maxipime)
Cefepime, a fourth-generation cephalosporin, is used for the treatment of Pseudomonas infections. Its gram-negative coverage is comparable to that of ceftazidime, and cefepime has better gram-positive coverage. Cefepime is a zwitter ion that rapidly penetrates gram-negative cells. It is the best beta-lactam antibiotic for intramuscular (IM) administration. Cefepime's poor capacity to cross the blood-brain barrier precludes the drug's use for meningitis treatment.
Vancomycin
Vancomycin is used to treat enterococcal infections when ampicillin is contraindicated because of significant penicillin allergy and when strains are resistant to ampicillin but susceptible to vancomycin. Target levels of 30-50 µg/mL (peak) and 10-15 µg/mL (trough) for endocarditis and other serious infections. Patients with SIRS often require increased dosages to achieve target concentrations, especially patients with higher creatinine clearances.
Levofloxacin (Levaquin)
Levofloxacin, a second-generation quinolone, acts by interfering with deoxyribonucleic acid (DNA) gyrase in bacterial cells. A bactericidal drug, levofloxacin is highly active against gram-negative and gram-positive organisms, including Pseudomonas aeruginosa.
Corticosteroids
Class Summary
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune system to diverse stimuli. The initial research in sepsis and septic shock showed a trend toward worse outcomes when treating with high doses of steroids (methylprednisolone sodium succinate 30 mg/kg every 6 h for 4 doses) compared with placebo. However, research into low-dose steroids (200-300 mg of hydrocortisone for 5-7 days) improved survival and the reversal of shock in vasopressor-dependent patients.
Hydrocortisone sodium succinate or phosphate (Cortef, Solu-Cortef)
This is the drug of choice for steroid replacement in acute adrenal crisis and for daily maintenance in patients with Addison disease or secondary adrenocortical insufficiency. It has glucocorticoid and mineralocorticoid properties. The biologic half-life is 8-12 hours. The easiest way to set up an infusion is to have the pharmacy mix 100 mg of hydrocortisone in 100 mL of 0.9% saline.
Antidiabetic Agents
Class Summary
These agents are used to treat hyperglycemia. A reduction of in-hospital mortality rates by 34% has been reported with intensive insulin therapy (maintenance of blood glucose at 80-110 mg/dL.
Insulin regular human (Humulin, Novolin, Humalog)
This is an ultra–short-acting insulin analog. Insulin suppresses hepatic glucose output and enhances glucose uptake by peripheral tissues. Insulin also suppresses ketogenesis and lipolysis, stimulates proper use of glucose by the cells, and reduces blood sugar levels.
Antifungals, Systemic
Class Summary
Empiric antifungal therapy (fluconazole or an echinocandin) can be considered in patients who have already been treated with antibiotics, patients who are neutropenic, patients who are receiving total parenteral nutrition (TPN), or patients who have central venous access in place.
Fluconazole (Diflucan)
Fluconazole is a synthetic triazole antifungal (broad-spectrum bistriazole) that selectively inhibits fungal CYP450 and sterol C-14 alpha-demethylation, which prevents conversion of lanosterol to ergosterol. It is used to treat mild-to-moderate infections or severe or life-threatening infections in patients intolerant of amphotericin B. Metabolic clearance is prolonged in renal dysfunction.
Caspofungin (Cancidas)
Caspofungin is the first of a new class of antifungal drugs (glucan synthesis inhibitors). It inhibits synthesis of beta-(1,3)-D-glucan, an essential component of the fungal cell wall. It is used to treat refractory invasive aspergillosis.
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A Venn diagram of the systemic inflammatory response syndrome (SIRS). The diagram shows the overlap between infection, bacteremia, sepsis, SIRS, and multiorgan dysfunction. This perspective shows that not only infection can cause SIRS. Courtesy of emDocs.net (http://www.emdocs.net/mimics-of-sepsis/).
