CLINICAL REVIEW &DECISION

THEN FOCUS

AT 48 - 72 HOURSSTART SMART

Do not start antimicrobials in the absenceof evidence of bacterial infection

Clinical review Check microbiology Make & document decision Include stop date or duration on all

orders for antimicrobial treatment

3. CHANGEto narrow spectrum agent

Initiate prompt effective antimicrobial treatment within one hour of diagnosis (or as soon as possible) in patients with life threatening infections 2. IV/oral1. STOP 5. OPAT*SWITCH Comply with local prescribing guidance Document clinical indication and dose on chart and in clinical notes

DOCUMENT DECISION

Antimicrobial Prescribing Decision * Outpatient Antibiotic Therapy

Medication orders for antimicrobial drugs not stating the number of doses or days will be subject to a safety notification and an Autostop

(72 hours for restricted antimicrobials, 7 days for all others).

Surgical Prophylaxis AlgorithmSINGLE DOSE SURGICAL PROPHYLAXIS

Clean surgery involving placement of a prosthesis or implant DO

CUMENT

Clean contaminated surgery

Contaminated surgery

*If prolonged surgery: repeat prophylaxis dosecefazolin 2 g IV x single dose 30 minutes prior to incisionbroaden coverage

Clean surgery:Contaminated surgery:Known MRSA or penicillin allergic: vancomycin 20 mg/kg x 1 dose 60 minutes prior to incision

This document was adapted from the National Health Service, Department of Health, Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection, Antimicrobial Stewardship: ''Start Smart - Then Focus'', 18 Nov 2011: pages 13, 14. Contains public sector information licensed under the Open Government Licence v1.0. 23 Jul 2012 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131181.pdf

Take history of relevant allergies

Ensure relevant microbiological specimens taken

*

4. CONTINUEAND REVIEWagain after a further 24 hours

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Antimicrobial StewardshipRIGHT DRUG. RIGHT DOSE. RIGHT DURATIONEVERY PATIENT

Surgical ProphylaxisONE DOSE

Within 60 minutes before knife to skin

October 2012

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280341 Rev. Oct 31, 2012 R-1

ANTIMICROBIAL GUIDANCE FOR HOSPITAL ADULT INPATIENTS NOTE: Doses recommended are based on normal renal function; review local antibiograms for resistance

patternsSepsis Criteria: Signs of infection PLUS 2 or more of the following:Temp > 38 or < 36 / Respiratory rate > 20/min / Pulse > 90 beats per min / WBC < 4 or > 12 and > 10% immature white cellsSEPSIS

NYD Piperacillin/tazobactam (3.375 g IV q6h). If MRSA risk, add vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing)PNEUMONIA* * For community acquired

pneumonia (CAP), hospital acquired pneumonia (HAP), ventilator associated pneumonia (VAP) and aspiration pneumonia: Refer to specific guidelines for recommendations

Mild: amoxicillin (1 g PO TID) PLUS macrolide (clarithromycin XL 1 g PO daily OR azithromycin 500 mg PO/IV daily) x 5-7 daysModerate: ceftriaxone (2 g IV q24h) PLUS macrolide (see above) x 7-10 daysSevere: piperacillin/tazobactam (3.375 g IV q6h) PLUS macrolide (see above) x 7-10 daysLUNG

If suspect MRSA: Add vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing) If suspect Pseudomonas: piperacillin/tazobactam (4.5 g IV q6h) OR tobramycin (6 mg/kg IV q24h) x 14 daysInfectious Diseases consult recommended for all severe cases

ENDOCARDITIS - Start empirical therapy and Infectious Diseases consultation recommended for ALL casesNative Valve: Vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing) PLUS ceftriaxone (2 g IV q24h)

lf penicillin allergic: replace ceftriaxone with gentamicin (1 mg/kg IV q8h)HEART Prosthetic Valve: Surgical Consult

Vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing) PLUS gentamicin (1 mg/kg IV q8h) PLUS rifampin (300 mg PO q8h)Duration of Rx depends on organism involved

BACTERIAL MENINGITIS - Infectious Diseases consult recommended for ALL casesAge < 50: ceftriaxone (2 g IV q12h) PLUS vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing) PLUS dexamethasone (0.15 mg/kg IV q6h x 4 days

- dexamethasone to be started 10 -15 minutes before or with first dose of antibiotic for presumptive S. pneumoniae meningitis)CNS Age > 50 or immunocompromised: above PLUS ampicillin (2 g IV q4h)

Post neurosurgery: vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing) PLUS meropenem (1 g IV q6h)Duration of treatment: 7-21 days (depends on organism involved)SPONTANEOUS BACTERIAL PERITONITIS

NECROTIZING PANCREATITISINTRAABDOMINAL SEPSIS / PERITONITIS / CHOLANGITISPiperacillin/tazobactam (3.375 g IV q6h)

Piperacillin/tazobactamCeftriaxone 2 g IV q24h x 5 days [longer if bacteremic]

If suspect ESBL : Imipenem (500 mg IV q6h) (3.375 g IV q6h)Duration of treatment: 1 week if source controlled (i.e. drainage) If no source control: Infectious Diseases consult for prolonged therapy

CLOSTRIDIUM DIFFICILEGIDiscontinue inciting/unnecessary antibiotics, proton pump inhibitors and anti-peristaltic agents

Mild/moderate: metronidazole (500 mg PO/NG TID) x 10-14 days Severe:Fulminant:

vancomycin (125 mg PO/NG QID) x 14 days vancomycin (125 mg PO/NG QID) PLUS metronidazole (500 mg IV q8h)

Recurrent: vancomycin (125 mg PO/NG QID) x 14 days Infectious Diseases consult recommended

URINARY TRACT INFECTION Do NOT treat asymptomatic bacteriuria or patients with indwelling catheters with no symptomsCYSTITIS PYELONEPHRITIS

GU Ceftriaxone (2 g IV q24h) until afebrile, step down to oral to complete 14 daysSulfamethoxazole/trimethoprim (Septra) i DS tab PO BID x 3 days OR Nitrofurantoin (Macrobid) 100 mg PO BID x 5-7 days OR Ciprofloxacin 500 mg PO BID x 3 days

If suspect ESBL: imipenem 500 mg IV q6h x 14 days

UNCATHETERIZED MALE UTI: Ciprofloxacin 500 mg PO BID x 7 days; prostatitis may require prolonged prescriptionCELLULITIS OSTEOMYELITIS: SEPTIC ARTHRITIS

Infectious Diseases consult recommendedObtain blood and joint cultures first

Oral: cephalexin Infectious Diseases consult recommended for ALL cases Obtain blood and/or bone cultures before antimicrobials(500 mg PO QID)

Vertebral:IV: cefazolin Acute:vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing)(1-2 g IV q8h) Monoarticular:PLUS ceftriaxone (2 g IV q24h) OR ciprofloxacin (400 mg IV q12h or 750 mg PO BID)

ceftriaxone 2 g IV q24hOther sites:Penicillin allergy:PLUS vancomycin (25 mg/kg IV x 1 vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing)clindamycin (300 mg PO q8h

then consult Pharmacy for furtherdosing)

PLUS gram negative agent [ceftriaxone (2 g IV q24h) ORor 600 mg IV q8h)

BONEciprofloxacin (400 mg IV q12h or 750 mg PO BID)]

OR vancomycinDiabetic foot associated:(20 mg/kg IV x 1 then consult

Pharmacy for further dosing) Polyarticular:Complicated: piperacillin/tazobactam (3.375 g IV q6h) PLUS vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing) if MRSA suspected

SKIN

ceftriaxone 2 g IV q24hIf suspect MRSA:Uncomplicated: clindamycin (600 mg IV/PO q8h)Associated abscess:Add vancomycin (25 mg/kg IV x 1 then consult Pharmacy for further dosing)

PLUS ciprofloxacin (750 mg PO BID)Add MRSA coverage -Chronic: Empiric therapy not indicated. Base antibiotic choice on culture results.[Vancomycin (25 mg/kg IV x 1

then consult Pharmacy for

Chronic:Duration of therapy:further dosing)

Empiric therapy not required immediately.Bone necrosis (no surgery): 6 -12 weeksInfected but viable bone: 4 - 6 weeks

OR Sulfamethoxazole/

Determine etiology.trimethoprim (2 DS tabs PO

Post amputation: no residual infected tissue: 2-5 daysBID)]Suppressive antibiotics may be needed if hardware cannot be removedRESTRICTED ANTIMICROBIALS: Consult Infectious Diseases within 24 hours to initiate Rx and for prolonged use. See Formulary for complete listing. Carbapenems Tigecycline Daptomycin

Gancyclovir Timetin (ticarcillin/clavulanate)(ertapenem imipenem, meropenem) Caspofungin Valgancyclovir Linezolid Cefotaxime Liposomal Amphotericin B Voriconazole Cefoxitin

Review IV therapy daily.- Oral switch as soon as possible - Always use narrow spectrum agents when possible- Stop therapy if bacterial infection unlikely!

RIGHT DRUG. RIGHT DOSE. RIGHT DURATION ... EVERY PATIENT October 2012280341 Rev. Oct 31, 2012 R-1