It is the policy of the facility to initiate the Infection Protocol when a patient demonstrates suspected infection with 2 out of 4 of the Systemic Inflammatory Response Syndrome (SIRS) criteria and/or meets Quick Sequential Organ Failure Assessment (qSofa) criteria as well as the discretion of the medical provider. 

SIRS Criteria

• Temperature > 100 or < 96.8
• HR > 90 bpm
• SBP < 100 
• RR > 20
• O2 sat < 92% 
• Altered mentation (GCS < 15 or change from patient’s baseline)
• WBC > 12K or < 4K

AND/OR

qSofa

• SBP < 100 
• RR > 22
• Altered mentation (GCS < 15 or change from patient’s baseline)

Sepsis Team includes: 

Initiating Physician, Nurse Practitioner and RN Supervisor, Primary RN, Certified Nurse Aide

High Risk Patients to be Placed on Protocol are defined as having:

• Active Infection- Patients admitted to facility on antibiotic
• Recent Infection- Patients who received antibiotics for an infection during their hospital course
• Patients with positive SIRS criteria upon admission
• MD Discretion- Patient’s deemed to be at high risk for infection by PMD who do meet the above criteria.

PROCEDURE: High Risk Patients (Screening/Identification and Stratifying of Patients)

1. Licensed Nurse will screen all patient’s upon admission/ongoing for infection based on diagnosis and clinical assessment.
2. Clinical Assessment includes but is not limited to the following criteria:
   1. Assess patient for symptoms/signs of Infection:
   2. Is the patient SOB?
   3. Does patient have AMS (compared to baseline)?
   4. Is the patient weaker than their baseline or change in ability to complete ADLs?
   5. Is the patient coughing?
   6. Does the patient have cellulitis or an actively draining wound?
   7. Does the patient complain of urinary symptoms, have foul smelling/bloody urine, or have increased/decreased urinary frequency?
   8. Decreased PO intake?
   9. Nausea/Vomiting/Diarrhea?
3. Notifies the physician and communicates assessment information using the SBAR and confirms treatment plan.
4. Physician/designee will initiate the infection protocol and stratifies patient to the appropriate level of infection protocol.  Determines the appropriate medications/treatments in accordance with Antibiotic Stewardship Program.
5. Nurse Supervisor/designee will complete the Infection Protocol Clinical Action Worksheet and submits to the Infection Preventionist/Designee.
6. Licensed nurse administers medications and treatments as ordered.
7. Medical provider to order baseline labs and cultures and sensitivity.
8. Monitor patient’s vital signs and urinary output, as ordered.
9. Initiate oxygen therapy as ordered. 
10. Verifies MOLST Orders.
11. Infection Preventionist/Designee will maintain a list of patients who have been placed on the infection protocol and discuss at morning report. Reviews and/or completes the Infection Protocol Clinical Action Worksheet.
12. NP or PMD will review patient’s infection protocol daily to monitor improvement/worsening of clinical symptoms.
13.  Medical providers to document evaluation of patient using the following criteria:
    1. Subjective Findings
    2. Objective Findings
    3. Diagnostics
    4. Assessment
    5. Treatment Plan
14. Antibiotic Review
    1. Antibiotic regimen will be reviewed by PMD within 24 hours
    2. If available, order infectious disease consult will be placed
15. Lab/CXR reporting
    1. Abnormal values will be immediately reported to medical provider.
16. Culture and Sensitivity data
    1. Results will be immediately reviewed/reported to medical provider
17. Licensed Nurse completes infection assessment every shift x 3 days and documents in using the Infection Control Progress Note. Notifies medical providers for any changes in vital signs or signs/symptoms concerning for an infection.
18. CNA will report any changes in residents’ condition to the nurse.
19. Infection control Preventionist/designee will compile and review weekly data from the program.

Infection Protocol Levels

Yellow Level

1. High risk admission/readmission- patient meets criteria for a high risk patient but does not have active infection.
2. Any admission with 1 positive SIRS criteria other than temperature or WBC.
3. Notify Medical provider
4. Initiates diagnostics within 6 hours
   1. UA and Urine culture
   2. Chest X-ray
   3. Comprehensive Metabolic Profile
   4. CBC with DIFF

Orange Level

If one of the following SIRS Criteria is met:

• Temperature > 100 or < 96.8
• HR > 90 bpm
• SBP < 100 
• RR > 20
• O2 sat < 92% 
• Altered mentation (GCS < 15 or change from patient’s baseline)
• WBC > 12K or < 4K

1. Notify Medical provider
2. Recheck vitals q12hr x 72 hours
3. Initiates diagnostics within 6 hours
   1. UA and Urine culture
   2. Chest X-ray
   3. Comprehensive Metabolic Profile
   4. CBC with DIFF
4. Initiates antibiotics protocol. If patient is already on antibiotic, MD will review and determine if patient should continue current regimen or change.
5. IVF if indicated.
6. Oxygen Therapy
7. Antipyretics
8. Monitor  Urine Output

Red Level

Meets all orange level criteria and one of the following criteria

1. qSofa Score ≥ 1
2. Tachycardia > 100
3. Notify PMD/Designee
4. Recheck vitals q4hr 
5. Initiate diagnostics (within 12 hours)
1. UA and urine culture 
2. Chest x-ray
3. Comprehensive Metabolic Profile QD x3 days
4. CBC with Diff
5. Blood culture
6. Initiate treatment (within 2 hours)
   1. If heart failure on diagnosis list the verify rate/fluids with provider 
   2. Utilize Mean Arterial Pressure (MAP) to guide decisions regarding IVF Therapy
1. Place IV
2. Start Antibiotic Protocol 
3. Start normal saline at 250 ml/H x 2 H, then at 100 mL per hour for a total of 2L 
7. Oxygen Therapy
8. Antipyretics
9. Monitor  Urine Output

* WBC or Temp MUST be one of the two criteria

Guidelines for Antibiotic Selection

Unknown Source of Infection

• If patient has a history of recent infection in the last 6 months, then reinstate the last antibiotic regimen.
• If no history of recent infection, then start:
  • Cefepime 1G IV x 1 dose(renal adj)
  • Vancomycin 1g IV x 1 dose 
• If patient has diarrhea then consider po metronidazole
• Timing: If unable to obtain IV access within 2 hours, administer cefepime IM

Pneumonia (Non-Aspiration)

Orange Level Treatment: Unknown Source Of Infection

(Choose One of the Following)

• Amoxicillin-clavulanate 875/125 mg po BID + Azithromycin 500mg po x 1 on Day 1, then 250mg po q24h x 4 days
• Levofloxacin 750mg po q24h 

Red Level Treatment

(Choose One of the Following)

• Piperacillin-tazobactam 4.5g IV q6h
• Cefepime 2g IV q8h
• Levofloxacin 750mg IV q24h

Supplemental Regimen

• Add Vancomycin 15-20 mg/kg IV q8-12h pending results of sputum Gram-stain and cultures for following:
  • influenza-associated
  • severe pneumonia

Pneumonia (Aspiration)

Orange Level Treatment

(Choose One of the Following)

• Amoxicillin-clavulanate 875/125mg po bid
• Moxifloxacin 400mg po q24h
• Clindamycin 300-450mg po tid

Red Level Treatment

(Choose One of the Following)

• Ceftriaxone 1g IV q24 + Metronidazole 1g IV q12h
• Ampicillin 3g IV q6h
• Piperacillin-tazobactam 4.5g IV q6h 
• Ertapenam 1g IV q24h

Urinary Tract Infection

Orange Level Treatment:

(Choose One of the Following)

• Trimethoprim/sulfamethoxazole 160mg TMP po q12h
• Ciprofloxacin 250mg po bid
• Levofloxacin 250mg po bid
• Amoxicillin-clavlanate 875/125mg bid
• Cephalexin 500mg po qid

Red Level Treatment:

(Choose One of the Following)

• Piperacillin-Tazobactam 3.375g IV q6h
• Imipenem 0.5g IV q12h
• Meropenam 1g IV q8h
• Cefepime 2g IV q12

Cellulitis (non-diabetic)

Orange Level Treatment:

(Choose One of the Following)

• Penicillin V-K 500mg po QID
• Amoxicillin 500mg po q8h
• Cephalexin 500mg po QID

Red Level Treatment:

(Choose One of the Following)

• Penicillin G 1million units IV q6h
• Cefazolin 1g IV q8h
• Ceftriaxone 2g IV q24h
• Vancomycin 15mg/kg IV q12h

Cellulitis (Diabetic)

Orange Level Treatment

(Choose One of the Following)

• TMP-SMX double strength 1-2 tabs po bid + Penicillin VK 500mg po QID 
• TMP-SMX double strength 1-2 tabs po bid + Cephalexin 500mg po QID

Red Level Treatment

(Choose One of the Following)

• Imipenem 0.5mg IV q6h + Vancomycin 1g IV q12h
• Daptomycin 4mg/kg IV q24h
• Linezolid 600mg IV bid

C. Difficile

• If possible, discontinue offending antibiotic, hydrate, and place in enteric isolation
• Mild Disease: Metronidazole 500 mg po tid x 10-14 days
• More severe disease:
• Vancomycin125 mg po qid x 10-14 days
• FIdaxomicin 200 mg po bid x 10 days
• Severe disease: 
  • Metronidazole 500 mg IV q6h + Vancomycin 125 mg q6h po ± retention enema of Vancomycin 500 mg in 500 mL normal saline q6h.

Responsibility

The Medical Director shall monitor compliance to this policy and procedure.