Antibiotic Policies HSE South Hospitals
Introduction
Antibiotic Policy Appendices
- Appendix 1 Switching from IV to PO therapy
- Appendix 2 Aminoglycoside monitoring
- Appendix 3 Vancomycin
- Appendix 4 Clostridium difficile diarrhoea
- Appendix 5 MRSA
- Appendix 6 Renal impairment, antibiotics
- Appendix 7 IV preparations
- Appendix 8 Prescribing Tips
- Prophylaxis - Endocarditis
- Prophylaxis - Meningitis
- Prophylaxis - Post Splenectomy /Hyposplenic
- Penicillin Allergy
Antimicrobial Prescribing Tips (Mala Shah CUH)
LRTIs:
- Piperacillin-tazobactam should not be used for the empiric treatment of community acquired pneumonia.
- Ciprofloxacin should not be used to treat community acquired LRTIs, and should not be used as a sole agent for empiric treatment of hospital acquired LRTIs as it has poor activity against S. pneumoniae.
UTIs:
- Ciprofloxacin and trimethoprim should not be used for empiric treatment (resistance).
Warfarin drug interactions:
- INR must be closely monitored and warfarin doses adjusted for antimicrobials, particularly macrolides (Clarithromycin*, Erythromycin).
Monitoring levels:
- Gentamicin, Vancomycin, tobramycin, streptomycin and amikacin levels must be monitored appropriately and where possible. resistance.
Vancomycin Loading Dose then
ALL patients should receive a Vancomycin Loading Dose (hover for details) then 15mg/kg maintenance (assuming normal renal function).
Teicoplanin:
- Should be dosed according to patient weight.
- A standard dose is 6mg/kg (round up to the nearest 200mg): Seek advice. Don’t forget the loading dose (q12h for first 3 doses, then q24h thereafter).
IV to PO switch:
- Use oral treatment where possible for: ciprofloxacin, metronidazole, Clarithromycin*, Moxifloxacin **, Linezolid, Fluconazole, Rifampicin, Clindamycin.
Reviewing treatment:
- Always document indication for antimicrobial and proposed duration of treatment.
- Always review cultures daily
- Seek advice if unsure
- Review need for antimicrobial therapy daily. Prolonged therapy can lead to resistance and serious adverse effects, e.g. C. difficile.
- Respect the restricted access policy.
- If in doubt, always seek advice!
- Microbiology: extension 22504 / 22694
- Infectious Diseases SpR: bleep 203
- Antimicrobial Pharmacist: bleep 479
- Pharmacy: extension 22146 / 22542
* Clarithromycin can cause significant INCREASE ↑ in INR. For patients on Warfarin and Clarithromycin*, INR must be monitored very closely.
Before starting antibiotics
- The decision to prescribe an antibiotic must be based on clinical evidence of infection. Establish a provisional diagnosis. This will give an indication of the most likely causative organisms, and the most suitable empiric treatment.
- If possible, take samples (especially blood cultures) for culture and sensitivity testing before starting antibiotics. In certain circumstances, e.g. suspected bacterial meningitis, antibiotics should be given immediately. In patients with life threatening infections, do not delay empirical therapy whilst awaiting microbiology results.
- Consider the patient’s medical history when deciding on treatment options: check allergy status, renal and hepatic function, pregnancy or breast feeding and concomitant medication. Refer to the BNF for drug – drug interactions.
- If there has been a history of anaphylaxis with penicillin avoid the following antibiotics: all beta lactam antibiotics (e.g. penicillin, flucloxacillin, amoxicillin, ampicillin, co-amoxiclav, piperacillin-tazobactam, meropenem) and cephalosporins.
- There is a 10% cross- sensitivity with cephalosporins in penicillin allergy and they may be trialled in patients with a penicillin allergy that was not severe, e.g. mild rash only. Ensure allergy box is completed on the drug charts and cover of notes.
- Take account of recent culture reports as empiric treatment may require modification as a result: e.g. recent MRSA culture.
• Recent antibiotic use - consider use of an antibiotic from a different class, if suitable. - Always document the reason why an antibiotic is commenced, and the proposed duration of treatment.
- Take appropriate samples. Refer to the Laboratory Users Manual.
- A microbiology result should not be examined in isolation: treat the patient, not the result. The sensitivity profile on the report is not necessarily a recommendation to treat with antibiotics, as organisms of no clinical significance may grow from non-sterile sites (colonisation).
Reviewing antibiotic treatment
- Review need and choice of antibiotic daily
- When sensitivities are known, change to the narrowest spectrum agent to which the culture is sensitive. If in doubt, seek advice.
- Route of administration – see Appendix 1 for iv to oral switch policy.
- Duration of treatment: in general, most antibiotic courses need not exceed 5-7 days. Unnecessarily prolonged courses may result in unwanted side effects (e.g. pseudomembranous colitis) and may contribute to the selection of resistant organisms, e.g. MRSA and VRE. Some infections will require a longer duration of treatment: e.g. endocarditis, severe pneumonia and bone and joint infections.
- Antibiotic level monitoring: some antibiotics need levels monitored to avoid toxicity. These include Vancomycin Loading Dose (hover) then, gentamicin, tobramycin, amikacin and streptomycin. Plesae seee Appendices 2 (Aminoglycosides) and 3 (Vancomycin) for details.
Actual body Weight |
IV Vancomycin Loading Dose |
IV infusion |
|---|---|---|
<40kg |
750mg |
In 250ml saline over 90mins |
40-59Kg |
1 gram |
In 250ml saline over 120mins |
60-90Kg |
1.5 grams |
In 500ml saline over 180mins |
>90kg |
2 grams |
in 500ml salivne over 240mins |
Resistance
The development of antimicrobials is generally accepted as the most significant medical development of the last century. In addition to saving thousands of lives, antimicrobials have enabled advances such as the use of cytotoxic chemotherapy, the use of immunosuppressive drugs, transplantation and other types of surgery. The problem of antimicrobial resistance (AMR), however has been recognised since the introduction of penicillin into clinical practice in the 1940s. In the past, the development of new agents partially compensated for this problem. However, over the last 15 years the prevalence of AMR has continued to escalate and the number of new classes of antibacterial drug marketed has been extremely limited.
AMR is now accepted as a major public health threat and is associated with excess morbidity and mortality, prolongation of hospital stay and epidemics of infection, and increased antibiotic costs.
The prevention of spread of antimicrobial resistance focuses on two main strategies: ensuring the appropriate use of antimicrobials and good hygiene.
When agreeing local guidelines in relation to antimicrobial use it is important to consider local variations in resistance rates. These guidelines have been developed taking into account locally available data.
Exposure to antibiotics increases the rate of emergence of resistant strains. Therefore it is important to use antibiotics only when clinically indicated, for the shortest effective duration and using an appropriate dose. Resistant organisms are especially important in a hospital setting and outbreaks of cross infection may be facilitated by inappropriate use of antibiotics. Because of this, some antibiotics are restricted and usually only prescribed after specialist advice.
Prescribers will be advised to seek specialist advice as outlined below before these antimicrobials are dispensed by the Pharmacy Department.
Restricted Antimicrobials
Exposure to antibiotics increases the rate of emergence of resistant strains. Therefore it is important to use antibiotics only when clinically indicated, for the shortest effective duration and using an appropriate dose. Resistant organisms are especially important in a hospital setting and outbreaks of cross infection may be facilitated by inappropriate use of antibiotics. Because of this, some antibiotics are restricted and usually only prescribed after specialist advice.
Prescribers will be advised to seek specialist advice as outlined below before these antimicrobials are dispensed by the Pharmacy Department.
Antimicrobial |
Restricted to: |
Meropenem |
Microbiology / Infectious Diseases / Respiratory Consultant only |
Ceftazidime |
Microbiology / Infectious Diseases / Respiratory Consultant only |
Linezolid |
Microbiology / Infectious Diseases / Respiratory Consultant only |
Aztreonam |
Microbiology / Infectious Diseases / Respiratory Consultant only |
Daptomycin |
Microbiology / Infectious Diseases only |
Tigecycline |
Microbiology / Infectious Diseases only |
Ambisome® (liposomal amphotericin) |
Microbiology / Infectious Diseases / Haematology Consultant only |
Caspofungin |
Microbiology / Infectious Diseases / Haematology Consultant only |
Voriconazole |
Microbiology / Infectious Diseases only |
Posaconazole |
Microbiology / Infectious Diseases only |
The following antibiotics are not used at CUH, in adults.
- Imipenem (alternative: meropenem)
- Cefotaxime (alternative: ceftriaxone. Cefotaxime reserved for use in neonates and children)
- Ampicillin (alternative: amoxicillin)
- Oral cephalosporins (except oral cefalexin for treatment of urinary tract infection).
- Oral cefuroxime (poor bioavailability, so reserved for treatment of UTI sensitive only to cefuroxime. Use co-amoxiclav if an oral stepdown needed from iv cefuroxime, seek advice in penicillin allergy)
- Oral penicillin (alternative: oral amoxicillin, as penicillin has poor bioavailability. Exception: patients on long-term oral penicillin post splenectomy)
Meningitis
Treatment should not be delayed pending investigations.
Specimens for collection: blood: for culture, glucose and EDTA blood for meningococcal & pneumococcal PCR, CSF: for microscopy and culture, glucose estimation and PCR, Throat swab for culture: labelled ‘? N. meningitidis’.
Once pathogen is identified, treatment should be tailored to the narrowest spectrum agent that is sensitive. Seek microbiology advice.
Neurological. Please click for antibiotic advice
Infection |
Most likely organisms |
1st line empiric treatment |
In penicillin allergy |
Comments |
Adult meningitis |
Neisseria meningitidis |
Ceftriaxone 2g q12h iv If Listeria monocytogenes meningitis suspected* add amoxicillin 2g q4h iv If resistant S. pneumoniae suspected** or |
Chloramphenicol 25mg/kg q6h iv |
Do not switch to oral therapy. Duration:
TB meningitis – seek advice on treatment and duration. If vancomycin used: maintain pre-dose levels 15-20mg/L. |
Encephalitis |
Herpes virus |
Aciclovir 10mg/kg q8h iv NB: use IBW to calculate aciclovir dose |
|
Send CSF for HSV PCR |
Post neurosurgery / CSF shunt |
Staph aurues |
Vancomycin Loading Dose (hover) then 15mg/kg q12h iv PLUS |
Vancomycin Loading Dose (hover) then 15mg/kg q12h iv |
Vancomycin: maintain pre-dose levels 15-20mg/L. |
** Risk factors for resistant S pneumoniae: age <10 or >50 years, immunosupressed, prolonged hospital stay, frequent, prolonged or prophylactic antibiotic use, recent visit to country with high rates of resistant S pneumoniae, e.g. Spain
*** Risk factors for TB meningitis: homelessness, alcohol abuse, immunosuppressed, recent immigration, recent contact with index case
Many upper respiratory tract infections are viral and do not require antibiotics
| Infection | Most likely organisms | 1st line empiric treatment | In penicillin allergy | Comments |
|---|---|---|---|---|
Acute |
Viruses S. pyogenes |
No antibiotic if viral Severe: Benzylpenicillin 1.2-2.4g q6h iv PLUS Metronidazole 500mg q8h IV / 400mg q8h po |
Clarithromycin* 500mg q12h po/iv. In severe, hospitalised cases, add Metronidazole 500mg q8h iv / 400mg q8h po |
Majority viral, most patients do not benefit from antibiotics. |
Vincents Angina |
Oral anaerobes | Benzylpenicillin |
Clindamycin 600mg q4h iv/po |
Duration: 10 days |
Acute sinusitis |
Viruses, Streptococci, |
No antibiotic if considered viral
Co-amoxiclav 625mg q8h po Doxycycline 200mg stat then 100–200mg q24h po |
No antibiotic if considered viral Clarithromycin* 500mg q12h po Or Doxycycline 200mg stat then 00–200mg q24h po |
Many attacks resolve without antibiotics. Consider allergic conditions or viral infection. Duration: 7-10 days |
Acute otitis media |
Viruses |
As for sinusitis, but see comments. |
Use pain relief for 24 hours before deciding whether antibiotic is required. |
|
Acute otitis externa |
See comments |
Antibiotics often not indicated unless cellulitis present. In malignant otitis externa (Pseudomonas), seek advice. |
||
Acute epiglotitis |
H influenzae |
Ceftriaxone 2g q12h iv |
Moxifloxacin ** 400mg q24h po/iv |
Duration: 10 days |
Oro-pharyngeal / peri-tonsillar abscess |
S pyogenes anaerobes |
Benzylpenicillin 1.2-2.4g q6h iv |
Clarithromycin* 500mg q12h po |
Seek surgical review, as may require drainage. |
*Clarithromycin* can cause significant increases in INR. For patients on warfarin and Clarithromycin*, INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary.
** Note about moxifloxacin: It is contraindicated in clinically relevant heart failure with reduced left ventricular ejection fraction, in bradycardia, where there is a history of QT prolongation or history of symptomatic arrythmias. Moxifloxacin should not be used concurrently with other drugs that prolong the QT interval, e.g. amiodarone, sotalol, neuroleptics e.g. haloperidol, chlorpromazine. Seek advice from pharmacy. It is also contraindicated in patients with impaired liver function (Child PughC).There are ongoing concerns regarding hepatic and serious skin reactions with moxifloxacin. Only use when there is no other alternative.
Reference
Bisno AL et al. IDSA Practice Guidelines for the diagnosis and management of Group A Streptococcal Pharyngitis. CID 2002: 35, p113-125
| Infection | Most likely organisms | 1st line empiric treatment | In penicillin allergy | Comments |
|---|---|---|---|---|
Community acquired pneumonia |
S. pneumoniae |
Co-amoxiclav 625mg q8h po OR Clarithromycin* 500mg q12h po/IV OR Doxycycline 100mg q12h po
In MUH please useCo-amoxiclav 625mg q8h po OR Clarithromycin* 500mg q12h po/IV |
Clarithromycin* 500mg q12h po OR Doxycycline 100mg q12h po
In MUH please useClarithromycin* 500mg q12h po OR Moxifloxacin ** 400mg q24h po |
Risk of aspiration: add Metronidazole 400mg q8h po (not necessary with co-amoxiclav)
Duration: 7 days |
Community acquired pneumonia |
S. pneumoniae |
Co-amoxiclav 1.2g q8h iv
If recent co-amoxiclav use: Cefuroxime 1.5g q8h iv PLUS Clarithromycin* 500mg q12h iv/po
Oral stepdown: Co-amoxiclav 625mg q8h po PLUS Clarithromycin* 500mg q12h po
|
History of rash with penicillin: Cefuroxime 1.5g q8h iv PLUS Clarithromycin* 500mg q12h iv/po Oral stepdown: Doxycycline 100mg q12h po Severe penicillin allergy : Moxifloxacin ** 400mg q24h iv/po In MUH pleaae useCefuroxime 1.5g q8h iv PLUS Clarithromycin* 500mg q12h iv/po Severe penicillin allergy : Moxifloxacin ** 400mg q24h iv/po |
Duration: 7 days Switch to oral therapy when apyrexial and clinical parameters improving. Risk of aspiration: add Metronidazole 500mg q8h iv / 400mg q8h po (not necessary with co-amoxiclav)
|
Community acquired pneumonia |
S. pneumoniae |
Ceftriaxone 2g q24h iv Switch to oral therapy when apyrexial and clinical parameters improving. Oral: PLUS Clarithromycin* 500mg q12h iv/po
In MUH please use:Co-amoxiclav 1.2g q8h iv PLUS Clarithromycin* 500mg q12h iv If recent co-amoxoclav use: Cefuroxime 1.5g q8h PLUS Clarithromycin* 500mg q12h iv/po Switch to oral therapy when apyrexial and clinical parameters improving. Oral:
|
Ciprofloxacin 400mg q12h iv / 500-750mg q12h po Switch to oral therapy when apyrexial and clinical parameters improving. Penicillin allergy only: Moxifloxacin ** 400mg q24h po In MUH please use:Ciprofloxacin 400mg q12h iv / 500-750mg q12h po PLUS Vancomycin Loading Dose then 15mg/kg q12h iv Switch to oral therapy when apyrexial and clinical parameters improving. Penicillin allergy only: Moxifloxacin ** 400mg q24h po |
Perform pneumococcal and legionella urinary antigen test in all patients. Duration: 10 days Risk of aspiration: add Metronidazole 500mg q8h iv / 400mg q8h po If vancomycin used: maintain pre-dose levels 15-20mg/L.
|
Healthcare associated pneumoniaEarly onset:(ie: Inpatient <48 hrs from admission) |
Follow community acquired pneumonia guidelines |
|||
Healthcare associated / ventilator associated pneumonia (ie: Inpatient >48 hrs, |
Gram negative organisms S. aureus
|
Piperacillin-Tazobactam 4.5g q8-6h iv If septic / spetic shock: add Gentamicin 5-7mg/kg od iv (max 500mg) If MRSA pneumonia suspected, seek advice from microbiology / ID / respiratory medicine. In MUH please use:Piperacillin-Tazobactam 4.5g q8-6h iv If septic / spetic shock: add Gentamicin 5-7mg/kg od iv (max 500mg) If pseudomonas suspected Add Ciprofloxacin 400mg q8h iv/750mg q12h po If MRSA pneumonia suspected, seek advice from microbiology / ID / respiratory medicine. |
Ciprofloxacin |
Duration: 7 days if uncomplicated and early clinical improvement, otherwise 10-14 days days. If no clinical improvement after 48- 72 hours, consider MRSA cover and seek advice from Microbiology / ID / Respiratory Medicine. Tailor therapy according to culture and sensitivities If vancomycin used: maintain pre-dose levels 15-20mg/L.
In MUH please note:If risk of aspiration: add Metronidazole 500mg q8h iv/ 400mg q8h po |
Infective Exacerbation of COPD / bronchitis |
H. influenzae, |
Co-amoxiclav 1.2g q8h iv or 625mg q8h po |
Clarithromycin* 500mg q12h iv/po In MUH please use: Clarithromycin* 500mg q12h iv/po OR Moxifloxacin ** 400mg q24h po |
Duration: 7 days Contact Respiratory Medicine if no clinical improvement after 48- 72 hours.
|
Bronchiectasis |
Bronchiectasis: refer to Respiratory Medicine. |
|||
Pleural infection: |
S. pneumoniae, |
Co-amoxiclav 1.2g q8h iv OR Cefuroxime 1.5g q8h iv |
Clindamycin 600mg q6h iv/po |
Refer to Respiratory Medicine and review culture results. Duration: at least 3 weeks and consult with Respiratory Medicine. On clinical improvement, consider oral stepdown and consult with Respiratory Medicine regarding choice of antibiotics. If vancomycin used: maintain pre-dose levels 15-20mg/L. |
Pleural infection: |
Gram +ve and –ve organisms, anaerobes. |
Piperacillin-tazobactam 4.5g q8h-q6h iv PLUS Vancomycin Loading Dose (hover) then 15mg/kg q12h iv OR Teicoplanin 6mg/kg q12 h for 3 doses, then q24h thereafter PLUS Metronidazole 500mg q8h iv / 400mg q8h po Please note in MUH:Teicoplanin not used in MUH. Please use Piperacillin-tazobactam plus Vancomycin pluse Metronidazole as above |
Ciprofloxacin 400mg q8-12h iv/ 500-750mg q12h po PLUS |
|
Pneumocystis carinii Pneumonia (PCP) |
Pneumocystis carinii (jiroveci) |
Co-trimoxazole iv 120mg/kg/day in 3-4 divided doses (i.e. 1920mg q6h iv for a 65 kg patient) Oral stepdown: same dose as iv, (i.e. 1920mg q6h po for a 65 kg patient)
|
Duration 14-21 days. |
|
Cystic fibrosis exacerbations |
P. aeruginosa |
Always consult Respiratory Medicine. Choice of antibiotics will depend on patient history. |
||
* Clarithromycin* can cause significant increases in INR. For patients on warfarin and Clarithromycin*, INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary.
** Note about moxifloxacin: It is contraindicated in clinically relevant heart failure with reduced left ventricular ejection fraction, in bradycardia, where there is a history of QT prolongation or history of symptomatic arrythmias. Moxifloxacin should not be used concurrently with other drugs that prolong the QT interval, e.g. amiodarone, sotalol, neuroleptics e.g. haloperidol, chlorpromazine. Seek advice from pharmacy. It is also contraindicated in patients with impaired liver function (Child PughC).There are ongoing concerns regarding hepatic and serious skin reactions with moxifloxacin. Only use when there is no other alternative.
Very Severe Community Acquired Pneumonia |
Direct admission to ICU is for patients with very severe CAP. |
Either of the major or Any Three of the minor criteria defines very severe CAP |
Respiratory Rate >30breaths/min Uraemia>7mmol/L |
Major Criteria |
Invasive mechanical ventilation Septic shock with the need for vasopressors |
Switch from parenteral drug to the equivalent oral preparation |
This should be made as soon as clinically appropriate, in the absence of microbiologically confirmed infection. Patients should be haemodynamically stable and improving clinically, able to ingest oral medications and have a normally functioning GI tract. |
Discharge |
References:
- Guidelines for the management of community acquired pneumonia in adults: update 2009. British Thoracic Society Community Acquired Pneumonia in Adults Guideline Group Thorax 2009; Vol 64 (Suppl III)
- Infectious Diseases Society of America / American Thoracic Society Consensus Guidelines on the Management of Community -Acquired Pneumonia in Adults. Mandell L et al. CID 2007: 44 (Suppl 2)
- Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the Nritish Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy 2008; 62: 5-34
- Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia, American Thoracic Society. Am J Respir Crit Care Med 2005; 171: 388-416
- Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010, Davies H et al. Thorax 2010; 65: 1141-1153
| Infection | Most likely organisms | 1st line empiric treatment | In penicillin allergy | Comments |
|---|---|---|---|---|
Native valve endocarditis – blind treatment |
Streptococci |
Amoxicillin 2g q4h iv Always seek advice from microbiology. |
Vancomycin Loading Dose then 15mg/kg BD IV if no renal impairment PLUS |
Seek advice from microbiology. Duration: minimum 4-6 weeks. Seek advice from microbiology. |
Prosthetic valve endocarditis – blind treatment |
S. aureus |
Vancomycin Loading Dose then 15mg/kg BD IV if no renal impairment PLUS |
|
Seek advice from microbiology. Duration: at least 6 weeks. |
Staphylococcal endocarditis |
S. aureus (methicillin sensitive) MRSA Coagulase negative staphylococci
|
MSSA native valve: Flucloxacillin 2g q4h iv Gentamicin 1mg/kg q8h iv (see comment) MSSA prosthetic valve: Flucloxacillin 2g q4h iv Gentamicin 1mg/kg q8h iv (see comment) PLUS Rifampicin 600mg q12h po CNS or MRSA native /prosthetic valve: Vancomycin Loading Dose then 15mg/kg BD IV if no renal impairment |
Vancomycin Loading Dose then 15mg/kg BD IV if no renal impairment Gentamicin 1mg/kg q8h iv |
Seek advice from microbiology. Gentamicin duration: 3-5 days for native valves, two weeks for prosthetic valves
|
Streptococcal endocarditis |
Viridans streptococci |
Benzylpenicillin 2.4g q4h iv |
Vancomycin Loading Dose then 15mg/kg BD IV if no renal impairment |
Microbiology to advise as antibiotic regimen and duration depends on penicillin MIC values. |
Enterococcal |
Enterococcus faecalis |
Amoxicillin 2g q4h iv |
Vancomycin Loading Dose then 15mg/kg BD IV if no renal impairment |
Microbiology to advise as antibiotic regimen and duration depends on MIC values. |
Endocarditis:
- Take 3 sets of blood cultures before starting antibiotics, then begin treatment immediately.
- Consult microbiology.
- Treatment should be modified in consultation with microbiology when culture results available.
- Target serum drug levels:
- Vancomycin pre-dose level: 10-20mg/L (15-20mg/L for staphylococcal endocarditis)
- Vancomycin 1 hour post-dose level: 30-45mg/L
- Gentamicin pre-dose: ≤1mg/L
- Gentamicin 1 hour post dose: 3-4mg/L
References: Elliot TSJ et al. Guidelines for the antibiotic treatment of endocarditis in adults: report of the Working Party of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy 2004; 54: 971-981
Septicaemia
| Infection | Most likely organisms | 1st line empiric treatment | In penicillin allergy | Comments |
|---|---|---|---|---|
SepticaemiaSource unclear |
Coliforms |
Piperacillin-tazobactam 4.5g q8h iv If severe sepsis or septic shock add |
Ciprofloxacin 400mg q8-12h iv If severe sepsis or septic shock add |
Seek advice for oral options |
Skin / soft tissue / line-associated sepsis |
S. aureus (inc MRSA) |
Community acquired, no MRSA history: Hospital acquired / history of MRSA: |
Vancomycin Loading Dose (hover) then 15mg/kg q12h iv |
If peripheral line sepsis, remove line and replace at a different site. For central line sepsis, perform central and peripheral blood cultures. Remove line if possible. When microbiological results available, tailor antibiotic therapy where appropriate. |
Urinary tract sepsis |
Coliforms |
Piperacillin-tazobactam 4.5g q8h iv Gentamicin 5mg/kg iv stat (max 500mg q24h), depending on severity. Seek review of gentamicin |
Ciprofloxacin 400mg q8-12h iv PLUS Gentamicin 5mg/kg stat (max 500mg q24h). Seek review of gentamicin. |
|
Intra-abdominal sepsis |
Coliforms |
Piperacillin-tazobactam 4.5g q8h iv Seek review of gentamicin. |
Ciprofloxacin 400mg q8-12h iv PLUS
|
|
Neutropenic sepsis |
Aerobic gram negative rods Gram positives usually associated with central venous catheters |
Piperacillin-tazobactam 4.5g q6h iv If line infection suspected, add (Vancomycin Loading Dose (hover) then 15mg/kg q12h iv OR Teicoplanin 6mg/kg q12 h for 3 doses, then q24h thereafter) |
Ciprofloxacin 400mg q8h iv |
See neutropenic sepsis protocol for further information |
Systemic inflammatory response syndrome (SIRS) |
Sepsis |
Severe sepsis |
Septic shock |
Two or more of the following:
|
SIRS and documented infection (culture or gram stain of blood, sputum, urine or normally sterile body fluid positive for pathogenic microorganism; or focus of infection identified by visual inspection). |
Sepsis and at least one sign of organ hypoperfusion or organ dysfunction:
|
Severe sepsis and one of:
|
Notes: Always take blood cultures before commencing antibiotics. Development of septicaemia is often secondary to primary infection elsewhere. Therefore treatment will vary depending on primary condition
Reference:
- Septic Shock. Lancet 2005; 365: 63-78
Infection |
Most likely organisms |
1st line empiric treatment |
In penicillin allergy |
Comments |
|---|---|---|---|---|
Acute infectious diarrhoea |
Salmonella, Shigella, Campylobacter |
Usually no antibiotic treatment necessary. Seek advice if treatment required. |
|
|
Antibiotic associated diarrhoea |
Clostridium difficile
|
Metronidazole 400mg q8h po If severe or recurrent, refer to Appendix 4, p56-59 Consult microbiology if no improvement. |
|
Duration of treatment: 10 days. |
Intra-abdominal infections (cholangitis / cholecystitis / appendicitis) |
Gram negative organisms (e.g. E. coli) |
Mild – moderate: Severe: |
Mild-moderate community acquired: Severe community acquired or hospital acquired infection: Ciprofloxacin 400mg q12h iv PLUS Metronidazole 500mg q8h iv |
If MRSA risk: add either (Vancomycin Loading Dose (hover) then 15mg/kg q12h iv OR Teicoplanin 6mg/kg q12h iv for 3 doses then q24h thereafter) Duration: generally 5-7 days, with regular review. Switch to oral therapy when improving.
|
Peritonitis |
Primary: Coliforms |
Primary: Secondary: If faecal peritonitis: add Metronidazole 400mg q8h po / 500mg q8h iv |
Clarithromycin*500mg q12h iv/po |
Consider drainage in all cases.
|
CAPD peritonitis |
S. aureus |
Vancomycin Loading Dose (hover) then 30mg/kg body weight (max 3grams) intraperitoneally Refer to full CAPD peritonitis guidelines for more information |
Seek advice in severe penicillin allergy. |
See CAPD Peritonitis Guidelines for guidance in taking samples prior to initiation of antibiotics and for follow up doses of antibiotics. Maintain vancomycin levels between 15-20mg/L |
* Clarithromycin* can cause significant increases in INR. For patients on warfarin and Clarithromycin*, INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary.
Infection |
Most likely organisms |
1st line empiric treatment |
In penicillin allergy |
Comments |
|---|---|---|---|---|
Uncomplicated urinary tract infection |
E. coli |
Co-amoxiclav 625mg q8h po
|
Nitrofurantoin |
Duration: 3 days for women, 7 days for men. |
Complicated urinary tract infection (pyelonephritis) |
Coliforms |
Ciprofloxacin 500-750mg q12h po |
|
Duration: 7-14 days See p52 for gentamicin dosing guidelines. |
Catheter-related bacteriuria |
|
Usually antibiotics are not indicated. Only treat if clinical evidence of infection. Seek advice from microbiology. |
||
Prostatitis / epidydimo-orchitis |
Chlamydia trachomatis |
Acute and <35 years old: |
In severe penicillin allergy contact microbiology or Infectious Diseases for advice. |
For 10 days |
Pseudomonas Enterobacteriaceae |
Chronic or >35 years old: |
|
For 28 days. |
|
Pelvic inflammatory disease |
Chlamydia trachomatis |
Ceftriaxone 250mg stat im |
In severe penicillin allergy contact microbiology or Infectious Diseases for advice. |
Duration: 14 days |
Vaginal candidiasis |
Candida sp. |
Fluconazole 150mg po stat |
|
Consider bacterial vaginosis if not responding and malodorous discharge. |
For MUH patients, please see MUH GU Infecions Antibiotic Guidelines 2011
Infection |
Most likely organisms |
1st line empiric treatment |
In penicillin allergy |
Comments |
|---|---|---|---|---|
Cellulitis |
S. aureus |
Flucloxacillin 1-2g q6h iv Oral switch: |
Clarithromycin* 500mg q12h po/iv If severe cellulitis/ risk of MRSA consider adding either |
Duration 7-14 days If necrotising fasciitis is suspected see section below and contact surgical team. See vancomycin dosing guidelines |
Line infection |
S. aureus, Coagulase negative staphylococci and other organisms |
Take blood cultures prior to commencing antibiotics If gram negative organisms are suspected add Ciprofloxacin 400mg q12h iv or 500mg q12h po |
Contact microbiology for advice. See vancomycin dosing guidelines |
|
Necrotising fasciitis
|
Multiple organisms including Group A Streptococci
|
Flucloxacillin 2g q6h iv PLUS |
Clindamycin 600mg q6h iv |
Seek urgent surgical advice |
Gas gangrene |
Clostridium perfringens and other gas producing organisms |
Benzylpenicillin 2.4g q6h iv PLUS |
Clindamycin 600mg q6h iv |
Seek urgent surgical advice |
Infected burns |
Send swabs for cultures and sensitivities to direct therapy |
Apply silver sulphadiazine 1% cream to the affected areas. |
Clarithromycin* 500mg q12h iv/po |
|
MRSA infection |
Confirm with cultures and determine if colonisation or clinical infection |
|||
Surgical wound infection |
Following clean surgery
|
Flucloxacillin 1-2g q6h po/iv and if severe add Benzylpenicillin 1.2-2.4g q6h iv
|
Clarithromycin* 500mg q12h iv/po
|
Based on culture and sensitivity results and location of surgical site If patient is colonised with MRSA then consider adding (Vancomycin Loading Dose (hover) then 15mg/kg q12h iv OR Teicoplanin 6mg/kg q12h for 3 doses then q24h thereafter. |
Following contaminated surgery |
Cefuroxime 1.5g q8h iv OR Co-amoxiclav 1.2g q8h iv / 625mg q8h po |
Clarithromycin* 500mg q12h iv/po PLUS |
||
Diabetic foot infectionsTake good quality deep tissue swabs to identify organism to direct therapy prior to commencing antibiotics. Infections are often polymicrobial occasionally including MRSA and may require prolonged antibiotic courses so should be discussed with microbiology to advise on the most appropriate treatment. |
Superficial ulcer, without penetration into the deeper layers, with evidence of cellulitis |
Flucloxacillin 500mg-1g q6h po OR Co-amoxiclav 625mg q8h po |
Clarithromycin* 500mg q12h po |
Duration 7-14 days |
| Deep ulcer plus active cellulitis | Flucloxacillin 500mg-1g q6h po Flucloxacillin 1-2g q6h iv PLUS Ciprofloxacin 400mg q12h iv PLUS Metronidazole 500mg q8h iv |
Clarithromycin* 500mg q12h po PLUS Ciprofloxacin 500mg q12h po Clarithromycin* 500mg q12h iv |
Duration up to 6 weeks
Duration up to 6 weeks Consider oral switch on clinical improvement. |
|
Scabies |
1st line: Permethrim dermal cream (Lyclear®) applied over whole body including palms and soles (but not head and face). Leave on for 8 hours. Refer to infection control guidelines for isolation precautions. Follow manufacturers instructions |
|||
Human bites / Animal bites
|
Mainly oral flora |
Co-amoxiclav 1.2g iv q8h / 625mg q8h po if non-severe or on clinical improvement. |
Doxycycline 200mg q24h po day 1, then 100mg-200mg q24h thereafter |
Tetanus – consider tetanus vaccine / immunoglobulin. |
Septic arthritis, |
S aureus, group A Streptococci and other |
Flucloxacillin 2g q6h iv Consider addition of
|
Vancomycin loading dose then 15mg/kg q12h iv Consider addition of See vancomycin dosing guidelines. Vancomcyin pre-dose level: aim for 15-20mg/L. |
Duration of treatment;
. Always seek advice from microbiology
|
*Clarithromycin* can cause significant increases in INR. For patients on warfarin and Clarithromycin*, INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary.
Reference: Lawrence JE et al. Management of skin and soft tissue infections. JAC 2003; 52: Suppl S1:13-17
Infection |
Treatment |
|---|---|
Herpes simplex – |
Valaciclovir 500mg q12h po for 5 days If immunocompromised: Valaciclovir 1g q12h po for 10 days |
Genital herpes |
Valaciclovir 500mg q12h po for 5 days If immunocompromised: Valaciclovir 1g q12h po for 10 days |
Herpes simplex encephalitis |
Aciclovir 10mg/kg q8h iv for 14-21 days. Use IBW to calculate dose and reduce dose in renal impairment. See Appendix 6 for dosing. |
Varicella zoster opthalmicus |
Valaciclovir 1g q8h po for 10 days* |
Herpes zoster (shingles) |
Valaciclovir 1g q8h po for 7 days* |
Varicella zoster |
Valaciclovir 1g q8h po for 7 days Patients with high risk of severe disease: Aciclovir 10mg/kg q8h iv* |
*If IV treatment necessary: aciclovir 10mg/kg q8h iv (use IBW to calculate dose). Dose reduction necessary in renal impairment.
References:
- Tunbridge et al. Chicken pox in adults – clinical management. Journal of Infection 2008; 57: 95-102
- 2007 National Guideline for the Management of Genital Herpes. Clinical Effectiveness Group, British Society for Sexual Health and HIV
Infection |
Treatment |
Comments |
|---|---|---|
Oropharyngeal thrush |
Nystatin suspension 1ml q6h po |
If severe, add Fluconazole 50-100mg q24h po for 7-14 days. |
Vaginal thrush |
Clotrimazole pessary 500mg pv stat |
Add Fuconazole 150mg po stat if severe or not responding to clotrimazole pessary. |
Fungal skin infection |
Clotrimazole 1% cream q12h to affected areas |
|
Fungal nail infection |
Terbinafine 250mg q24h po |
Duration: 6 – 12 weeks (occasionally longer in toenails) |
Disseminated candidiasis |
Fluconazole 800mg iv stat then 400mg q24h iv. Always seek advice from microbiology. |
Consider oral switch when there is a clinical improvement. |
Aspergillosis |
Always seek advice from microbiology/ID |
|
Immunocompromised patients |
Always seek advice from microbiology/ID |
|
References:
- Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America
Infection |
Treatment |
Comments |
|---|---|---|
Bacterial conjunctivitis |
Chloramphenicol 0.5% eye drops every 2 hours initially, reduce to four times a day when infection controlled and Chloramphenicol 1% eye ointment at night |
Always take a swab. |
Preseptal cellulitis |
Co-amoxiclav 625mg q8h po Penicillin allergy: |
Consider Benzylpenicillin 1.2-2.4g q4-6h iv PLUS Flucloxacillin 1-2g q6h iv if severe infection or group A streptococci isolated. |
Orbital cellulitis |
Urgent referral to ophthalmology |
CT scan necessary. |
Herpes zoster ophthalmicus |
Valaciclovir 1g q8h po for 10 days |
Consider referral to ophthalmology. |
Suspected endophthalmitis |
Urgent referral to ophthalmology |
|
Corneal infection (keratitis) |
Urgent referral to ophthalmology |
|
*Clarithromycin* can cause significant increases in INR. For patients on warfarin and Clarithromycin*, INR must be monitored very closely and appropriate warfarin dose adjustments made as necessary.
Surgical Prophylaxis
Principles of Surgical Prophylaxis
- Prophylaxis should be started ideally within one hour prior to incision. Please note that certain antibiotics (e.g. vancomycin, erythromycin, Clarithromycin*, clindamycin and metronidazole) cannot be given as bolus injections. It is important that the infusions are completed within one hour PRIOR to incision to ensure adequate plasma levels during surgery.
- Prophylaxis should be confined to the peri-operative period (i.e. immediately before and during procedure). The administration of additional doses of antibiotic after the end of procedure provides little or no additional prophylactic benefit. The use of antibiotics post-procedure is strongly discouraged in most cases.
- Post operative doses of antibiotics will further disturb normal microbiological flora and increase the risk of Clostridium difficile. Only use post-operative antibiotics if specifically advised in the guideline or the patient requires treatment of infection (e.g. peritonitis post- perforated appendicitis). Antibiotic usage in this scenario is therapeutic rather than prophylactic.
- An additional peri-operative prophylactic dose should be considered by the surgeon for procedures lasting > 4 hours, or if there is blood loss >1500ml or haemodilution >15ml/kg
- Always check previous microbiology cultures and sensitivities (MC&S) to guide choice of antibiotic for surgical prophylaxis. If recent history of MRSA colonisation, a glycopeptide antibiotic should be given as part of surgical prophylaxis. Consult microbiologist.
- Clean surgery is associated with a low risk of infection and there is usually no indication for surgical antibiotic prophylaxis.
- NB: Vancomycin infusion must be run ONE HOUR PRIOR TO INCISION to ensure that adequate serum levels are achieved by time of incision
Type of surgery |
Procedures |
Recommended agents |
Comments |
|---|---|---|---|
Neurosurgery |
Craniotomy |
Cefuroxime 1.5g iv single dose Severe penicillin allergy: |
Single dose |
ENT |
Head and neck |
Co-amoxiclav 1.2g iv single dose Penicillin allergy: |
Only for clean-contaminated / contaminated surgery Single dose |
Cardiothoracic |
Coronary Artery Bypass Graft |
Cefuroxime 1.5g iv (q8h) Pencillin allergy / risk of MRSA: |
For 24-48hrs |
Prosthetic valve surgery |
Gentamicin 240mg (q24h) iv PLUS either (Vancomycin 1g (q12h) iv OR Teicoplanin 6mg/kg iv) |
For 24-48 hrs |
|
Pacemaker insertion |
Flucloxacillin 1g iv stat Penicillin allergy / risk of MRSA: |
Single dose |
|
General |
Appendectomy |
Co-amoxiclav 1.2g iv single dose In penicillin allergy: |
Prophylaxis not indicated for laparoscopic cholecystectomy or laparoscopic hernia repair without mesh. |
Breast |
Co-amoxiclav 1.2g iv single dose Penicillin allergy: |
Single dose |
|
Endoscopic retrograde cholangiopancreatography |
Ciprofloxacin 750mg po single dose one hour pre-op |
Single dose |
|
Vascular |
Aortic aneurysm |
Co-amoxiclav 1.2g iv (q8h) If risk of MRSA Co-amoxiclav 1.2g iv (q8h) In penicillin allergy: |
For up to 24 hrs only. |
Urology |
Transrectal prostate biopsy |
Oral option: Ciprofloxacin 750mg po PLUS Metronidazole 800mg po one-hour before procedure stat dose IV option: Gentamicin 3-5mg/kg IV PLUS Metronidazole 500mg IV ≤30minutes before procedure stat dose |
NB: Seek advice from Microbiology for ESBL colonised or other complex patients. |
Shock-wave lithotripsy |
Oral option: Ciprofloxacin 750mg po stat dose one-hour before procedure IV option: Gentamicin 3-5mg/kg IV ≤30minutes before procedure stat dose |
||
Percutaneous nephrolithotomy |
Only if stone >20mm or with pelvicalyceal dilation. If used, use Ciprofloxacin 500mg q12h oral for 7 days pre-procedure |
||
Endoscopic ureteric stone fragmentation/ removal |
Oral option: Ciprofloxacin 750mg oral single dose one-hour before procedure IV option: Gentamicin 3-5mg/kg IV at induction only |
||
Transurethral resection of prostate |
Gentamicin 3-5mg/kg IV at induction only If gentamicin contraindicated: Co-amoxiclav 1.2g IV at induction only (repeat at 4 hours if operation ≥4 hours). |
||
Radical cystectomy and nephrectomy |
Co-amoxiclav 1.2g IV at induction only (repeat at 4 hours if operation ≥4 hours) Penicillin allergy –Gentamicin 3-5mg/kg IV PLUS either (Vancomycin 1g iv OR Teicoplanin 6mg/kg iv) at induction only |
||
Orthopaedic |
Total hip replacement |
Cefuroxime 1.5g iv pre-op, then 750mg q8h iv for 2 doses Penicillin allergy: MRSA positive patients: |
For up to 24 hours only. Prophylaxis not recommended for elective orthopaedic surgery where there is no insertion of prosthetic device |
Obstetrics and gynaecology |
Hysterectomy |
Co-amoxiclav 1.2g iv single dose Pencillin allergy: |
|
Meningitis prophylaxis
Bacterial meningitis is a notifiable disease. Inform Public Health: Tel: x27363. They will advise on chemoprophylaxis of contacts.
Meningococcal Infection
Chemoprophylaxis is indicated only for close contacts, defined as those who, in the preceding seven days:
- shared living/sleeping accommodation with case
- were mouth kissing contacts
- were nursery/crèche contacts
- were boarding school dormitory contacts
Casual contacts, e.g. school classmates, playmates and neighbours are generally not considered to need chemoprophylaxis. Seek advice from Public Health or microbiology if unsure.
- Unless the index case has received ceftriaxone in hospital, chemoprophylaxis should also be given to the patient prior to discharge. When the disease has been treated with cefotaxime it may be prudent to give chemoprophylaxis until studies are available on its effectiveness in eradicating carriage.
- Only healthcare workers who do not wear a mask and whose mouth or nose is directly exposed to respiratory secretions and / or droplets, from a case of meningococcal disease are at risk.
Haemophilus influenzae type b (Hib) infection
Chemoprophylaxis is rarely indicated in Hib infection; only when there are unvaccinated or incompletely vaccinated children or persons at increased risk (e.g. asplenia or complement deficiency) in the household. Unless the index case has received ceftriaxone or cefotaxime in hospital, chemoprophylaxis should also be given to the patient prior to discharge. Seek advice from Public Health or microbiology if unsure.
Adults and children >12 years |
1st line: Rifampicin 600mg every 12 hours for 4 doses |
Female adults on the oral contraceptive pill |
Ciprofloxacin 500mg po stat |
Pregnant women |
Ceftriaxone 250mg im stat |
Children: 1-12 years |
Rifampicin syrup 10mg/kg every 12 hours for 4 doses |
Children 0 – 11 months |
Rifampicin syrup 5mg/kg every 12 hours for 4 doses |
Children and adults |
Rifampicin 20mg/kg once daily for 4 days up to max of 600mg/day |
Infants under 1 year of age |
Rifampicin 10mg/kg once daily for 4 days |
Pregnant women |
Not indicated |
Notes on rifampicin: Rifampicin may colour urine / tears red and stain contact lenses – do not wear contact lenses for a few days after rifampicin treatment. If on other drugs, check BNF / consult pharmacy regarding drug interactions with rifampicin.
Vaccination
If Haemophilus influenzae type b, pneumococcal meningitis or Neisseria meningitidis Groups C, A, Y and W135, vaccination of contacts and index may be indicated. Please refer to Public Health for advice.
References:
- British National Formulary 61 March 2011
- Immunisation Guidelines for Ireland 2008 Edition (Online update August 2010), National Immunisation Advisory Committee, Royal College of Physicians of Ireland
- Guidance for public health management of meningococcal disease in the UK 2011. Health protection agency (accessed via www.hpa.org.uk)
- Cochrane Database Syst Rev. 2006 Oct;(4):CD004785. Antibiotics for preventing meningococcal infections.
Moxifloxacin is contraindicated in clinically relevant heart failure with ↓ ventricular ejection fraction, in bradycardia, QT prolongation or history of symptomatic arrythmias.
Confusion |
|---|
Urea >7 |
Respiratory Rate >30 |
SBP <90mmHg DBP or <60mmHg |
Age >65 |
Septicaemia (Severe Sepsis and Sepsis in IVDU pages)
Always take blood cultures before commencing antibiotics. Development of septicaemia is often secondary to primary infection elsewhere. Therefore treatment will vary depending on primary condition.
Antibiotics are one part of an aggressive resuscitation policy. Please sees "severe sepsis" page.
Links
Infection Control Manual CUH, Infection Control Manual MUH
