guidelines for antimicrobial therapy - …cmcludhiana.in/cmc-hospital-antibiotic-policy2012.pdf ·...

(VALID TILL OCTOBER 2013)

GUIDELINES FOR

ANTIMICROBIAL THERAPY

FOR INTERNAL USE ONLY

Christian Medical College & HospitalLudhiana, Punjab (INDIA)

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Rub palms together. Rub the back of both hands.

Interface fingers and rub hands together. Interlock fingers and rub the back of fingers of both hands.

Rub thumb in a rotating manner followed by the area between index finger and thumb for both hands.

Rub fingertips on palm for both hands.

Rub both wrists in a rotating manner. Rinse and dry thoroughly.

WHO - Seven steps of Handwashing

DESCRIPTION Page

Editorial Note 5

Message from Director 6Message from Medical Superintendent 7Message from HOD - Microbiology 8Message from HOD - Medicine 9Antimicrobial Prescribing : Good Practices 10Monitoring Treatment 11The Importance of Infection Control (IC) toControl Antimicrobial Resistance 11Hypersensitivity 12Patient Risk Stratification 13How to use Pocket Guide? 14Antibiogram : Blood Stream Infection - ICU 15Antibiogram : Blood Stream Infection - IPD 15Antibiogram : Blood Stream Infection - OPD 16Antibiogram : Urinary Tract infections - ICU 16Antibiogram : Urinary Tract infections - IPD 17Antibiogram : Urinary Tract infections - OPD 17Antibiogram : Respiratory / Skin Soft Tissue infections - ICU 18Antibiogram : Respiratory / Skin Soft Tissue infections - IPD 18Antibiogram : Respiratory / Skin Soft Tissue infections - OPD 19Antibiotic Protocol : Blood Stream Infection - ICU 20Antibiotic Protocol : Blood Stream Infection - IPD 22Antibiotic Protocol : Blood Stream Infection - OPD 24

ContentsContents

DESCRIPTION Page

Antibiotic Protocol : Urinary Tract infections - ICU 26

Antibiotic Protocol : Urinary Tract infections - IPD 28Antibiotic Protocol : Urinary Tract infections - OPD 30Antibiotic Protocol : Respiratory / Skin Soft Tissue infections - ICU 32Antibiotic Protocol : Respiratory / Skin Soft Tissue infections - IPD 34Antibiotic Protocol : Respiratory / Skin Soft Tissue infections - OPD 36Notes 38Standard dosages of commonly used drugs 39Maximum daily dose of antibiotics 41Safe injection practices 42Antibiotic Summary Chart 44Irrational/Less evidence based antibiotics 46Categorization of Antibiotics 47Restricted use antibiotics : What and Why? 48Limited access antibiotics : What and Why? 49Under surveillance antibiotics : What and Why? 49Notes 50

ContentsContents

EDITORIAL NOTE

These guidelines were developed by a multi-disciplinary working group to ensure balanced input. It has considered the antimicrobial choice for specific conditions, and the existing policies for specific agents. The latest available evidence backed guidelines and recommendations were followed with due modification to the antibiotic choices where it was warranted by local antibiogram. We believe that by following the guidelines it will be possible to maintain a high standard of patient care, delivered in a consistent way across the Hospital. We recommend it to our colleagues.

This manual will be revised as and when new recommendations come or with the change in the local antibiogram.

This general guidance is not applicable to all patients. The choice of antimicrobial may need to be modified in the following situations:

• Hypersensitivity to first choice antimicrobial (see guidance on hypersensitivity)

• Recent antimicrobial therapy or preceding cultures indicating presence of resistant organisms

• In pregnant or lactating patients

• In renal or hepatic failure (see data for individual antimicrobials)

• Where significant drug interactions may occur.

Though the manual only provides a general guideline in choosing the antibiotic, it incorporates the best in antimicrobial therapy and hence any deviation must be justified in documentation in the case records. The compliance to general principles (as mentioned in the section – GOOD PRACTICE) is especially subjected to clinical audit as deviation in these aspects with out an evidence backed and peer approved reason will be considered as endangering the patient safety.

We welcome suggestions from our colleagues/readers.

Best Wishes

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MESSAGE FROM DIRECTOR

I am glad the Department of Medicine and particularly Infectious Diseases unit in collaboration with the Department of Microbiology, has taken the issue of antibiotic stewardship, a venture which was long overdue.

Antibiotics are blessing to human beings since its first discovery in the 1940's, to fight bacteria. Since then, further discoveries have taken place, following painstaking research and clinical trials. But we are still far away from major breakthrough in viral diseases and fungal ailments. The need of the hour is a guarded approach to use of antibiotics to prevent resistance, till new molecules could be evolved. Let us also not forget, no antibiotic is without side effects.

I would wholeheartedly support this venture of antibiotic stewardship in our multispecialty college and hospital.

With best wishes,

Yours sincerely

Dr. Abraham G. Thomas

Director

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MESSAGE FROM MEDICAL SUPERINTENDENT

CMC Ludhiana, A premier Medical Institute takes privilege in announcing and printing its ANTIMICROBIAL POLICY based on principles of evidence based medicine.

The discovery of antibiotics in the 20th century marked a watershed in the treatment of infections. However, the organisms countered this change effectively by becoming resistant. The hand book will be a significant step in the expansion of our knowledge in this direction and achieving better clinical outcome and rational use of antibiotics.

With best regards

Dr. Kanwal MasihMedical SuperintendentCMC & HospitalLudhiana

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MESSAGE FROM HOD-Microbiology

At the outset we wish to thank our Director Dr. A.G. Thomas, for his leadership and able guidance for achievement of this goal. Being Microbiologists, we come across multi-drug resistant pathogens on a daily basis. The extent of antimicrobial resistance has reached alarming proportions and poses a serious threat not only to the future of antimicrobials but also the patient's clinical outcome.

A robust infection control policy coupled with antimicrobial stewardship based on local microbiology data is the most suitable remedy to delay the menace of resistance from spreading fast. We are glad that finally we have such an antibiotic policy in place. We must thank the hospital management specially Dr. Kanwal Masih, our Medical Superintendent and all the senior clinicians mainly Dr. Mary John, Professor and Head, Medicine Department for providing their input in making this policy booklet. My sincere thanks owe to Dr. Sangeetha Mohan, Mrs. Shereen Rachel Varghese, Dr. Serene Varghese, Mr. Alvin and all Microbiology colleagues. We are sure to take necessary steps to ensure a strict and mandatory implementation of this antimicrobial policy booklet across the hospital.

With regards

Dr. Aroma Oberoi, MDProfessor & Head Microbiology Department CMC and Hospital Ludhiana

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MESSAGE FROM HOD-Medicine

Christian Medical College & Hospital, Ludhiana has always followed the highest standards of Medical Practices and Professional ethics. We are committed to provide quality health care to the community and maintain our status as a centre for medical excellence

It has been my long standing wish to see the evolution of antimicrobial policy for the hospital. We are glad that finally we have such an antibiotic policy in place. The addition of a qualified ID Physician to the Department of Medicine will help in the practical implementation of this policy.

It is essential that every department in the hospital should have a well structured and evidence based guidelines for the use of antimicrobials.

To highlight the importance of rational use of antibiotics, Antibiotic Stewardship workshop was organized in the hospital last year. As a logical outcome of the workshop, a consensual and comprehensive antibiotic policy for the hospital has been framed which is based on the following principles of Antibiotic Care:

a. Empirical antibiotics to be given based on site of infection and considering the possible pathogens causing such infections

b. The risk stratification for the presence of multi-drug resistant bugs should be done for every patient

c. Empirical antibiotics for Nosocomial infections to be prescribed based on the local microbiology data of the hospital

d. The practice of De-escalation to be encouraged based on the culture and sensitivity results and the patient's clinical condition

The antibiotic policy booklet will be available both at the outpatient and inpatient stations. I expect your full cooperation and compliance in following the antibiotic policy.

The current antibiotic policy is applicable for the year 2012-2013 and will be updated on an annual basis.

I seek your full support and cooperation in making this initiative a huge success

Best Regards,

Dr. Mary JohnHOD, MedicineCMC, Ludhiana

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1. Send for the appropriate investigations in all these infections as recommended. These are the minimum required for diagnosis, prognosis and follow up of these infections.

2. All antibiotic initiations would be done after sending appropriate cultures

3. Change in antibiotic would be done after sending fresh cultures

4. Follow the Hospital policy when choosing antimicrobial therapy whenever possible. If alternatives as chosen, document the reason in the case records.

5. Check for factors which will affect drug choice & dose, eg, renal function, interactions, allergy.

6. Check that the appropriate dose is prescribed. If uncertain, contact Infectious disease physician, Pharmacy, or check in the formulary.

7. The need for antimicrobial therapy should be reviewed on a daily basis. For most infections 5 – 7 days of antimicrobial therapy is sufficient (simple UTIs can be adequately treated with 3 days of antibiotic).

8. All IV antibiotics may only be given for 48 – 72 hours without review and consideration of oral alternatives. New microbiological or other information (eg fever defervescence for at least 24h, marked clinical improvement; low CRP) should at this stage often permit a switch to oral antibiotic(s), or switch to an IV narrow spectrum alternative, or cessation of antibiotics (no infection present).

9. Once culture reports are available, the physician shall step down to the narrowest spectrum, most efficacious and most cost effective option. If there is no step down availed, the reason shall be documented and is subjected to clinical audit.

10. Empiric Therapy - Where delay in initiating therapy to await microbiological results would be life threatening or risk serious morbidity, antimicrobial therapy based on a clinically defined infection is justified. Where empiric therapy is used the accuracy of diagnosis should be reviewed regularly and treatment altered/stopped when microbiological results become available.

11. Microbiological samples must always be sent prior to initiating antimicrobial therapy. Rapid tests, such as Gram smears, can help determine therapeutic choices when empiric therapy is required.

12. Prescribing antibiotics just in case an infection is present is rarely justified. Where patients are in hospital close observation is usually a better option.

ANTIMICROBIAL PRESCRIBING: GOOD PRACTICES

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The continued need for antimicrobial therapy should be reviewed at least daily. For most types of infection treatment should continue until the clinical signs and symptoms of infection have resolved – exceptions to this are indicated in the relevant sections. Parenteral therapy is normally used in seriously ill patients and those with gastrointestinal upset. Oral therapy can often be substituted as the patient improves.

Where treatment is apparently failing, advise from the microbiologist and ID Physician should normally be sought rather than blindly changing to an alternative choice of antimicrobial agent.

MONITORING TREATMENT

The use of antimicrobial agents inevitably leads to the emergence of resistant micro-organisms. It also destroys the normal flora of the body and renders patients far more susceptible to colonisation with micro-organisms introduced from elsewhere in the hospital through the process of cross infection.

THE IMPORTANCE OF INFECTION CONTROL (IC) TO CONTROL ANTIMICROBIAL RESISTANCE

Hospitals may be considered as reservoirs and breeding grounds within the world of antibiotic resistance.

Prevention of cross infection and good quality antimicrobial prescribing contribute to the prevention of antimicrobial resistance. Infection Control and Clinical Microbiology are inextricably linked.

The importance of hand washing in preventing hospital acquired infection and the spread of antibiotic resistant micro-organisms is clear.

High standards of hospital cleanliness may be important in controlling the spread of resistant organism in the environment e.g. MRSA, Acinetobacter baumannii

Surveillance is a crucial part of the control of antimicrobial resistance.

All patients should be asked about drug allergies. This is the responsibility of the doctor examining the patient. If a patient reports a drug allergy clarify whether this is an allergy or drug intolerance. In some cases there will be an overlap between drug allergy and drug intolerance.

Clinical features suggestive of drug allergy:

One or more symptoms developed during or following drug administration including difficulty in breathing, swelling, itching, rash, anaphylaxis, swelling of the lips, loss of consciousness, seizures or congestion involving mucous membranes of eyes, nose and mouth.

Clinical features suggestive of drug intolerance:

One or more symptoms developed during or following drug administration including gastrointestinal symptoms eg. nausea, vomiting, diarrhoea, abdominal pain and giddiness.

If patients are unable to give an allergy history, the doctor clerking in the patient should take reasonable steps to contact someone who can provide a reliable allergy history.

It is the prime responsibility of the prescribing doctor to ensure that;

i. The allergy box on the patients drug chart is completed when a new prescription chart is written or transcribed. If no allergy - specify "No known allergy or NKA". The box should be signed and dated. If allergy history cannot be obtained, then specify "history not available." Under no circumstances should the allergy box be left blank.

A pharmacist or nurse may complete the allergy box if the allergy status is documented in the clerking in notes.

ii. The allergy box is completed before prescribing a new drug, except in exceptional circumstances.

If patients have a suspected drug allergy then the drug and suspected reaction should be documented in the clerking-in notes and the drug chart.

HYPERSENSITIVITY

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PATIENT RISK STRATIFICATION

Patient Type 1

No contact with health care system

No prior antibiotic treatment in last 90 days

Patient young with no co-morbid conditions

Contact with health care system (e.g. recent hospital admission, nursing home, CAPD) without/minimal invasive procedures

Antibiotic therapy in last 90 days

Patient old ( > 65years) with few co-morbidities

Type 3 patient with fever despite antibiotic therapy (>5days) with no obvious source / after appropriate source control

± severe sepsis/septic shock PLUS

Has 1 or more than 1 of the following factors. (but not limited to) for invasive fungal infections: TPN, Hemodialysis, Immunodeficiency of variable origin, Major Abdominal surger y, Mult i - focal candida colonization, Diabetes

Hospitalization >5 days and or infections following invasive procedures

Recent & multiple antibiotic therapies

Patient with multiple Co-morbidities eg: cystic fibrosis, structural lung disease, advanced AIDS, neutropenia, other severe immunodeficiency

Patient Type 2 Patient Type 4Patient Type 3

• Bacterial infections with minimal risk of Multidrug resistant pathogens like ESBL producing Enterobacteriacae, MRSA or Non fermentors like Pseudomonas and Acinetobacter

• Invasive Fungal Infections are unlikely

• Risk of Bacterial infections with pathogens like ESBL producing Enterobacteriacae and MRSA.

• Minimal risk of Nonfermentors like Pseudomonas and Acinetobacter

• Minimal risk of Invasive Fungal infections .

• Risk of Bacterial infections with Pan-drug resistant Pseudomonas and Acinetobacter

• High Risk of Invasive fungal infections

• High risk of Bacterial infections with any of Multi drug resistant pathogens like ESBL producing Enterobacteriacae, MRSA and non-fermentors like Pseudomonas and Acinetobacter

• Risk of invasive fungal infections in special cases l ike patients undergoing Allogenic BMT, Liver transplant or chemotherapy induced neutropenic patients.

• Limited use of broad spectrum antibacterials

• No role of Antifungal agents

• ESBL infections to be treated with Non-Pseudomonal antibiotics like Group 1 Carbapenem

• BL+BLI’s can also be preferred for mild ESBL infections.

• Vancomycin/Tiecoplanin to be used for MRSA

• No role of Antifungal agents

• Bacterial infections to be treated with novel combination of antibacterials suggested for Pan resistant bacteria using alternate drug delivery systems/PK-PD parameters.

• Empiric treatment of fungal infections for both stable and unstable patients as per IDSA guidelines.

• Bacterial infections to be treated with broad spectrum antibiotics like Group 2. Carbapenem or Anti-Pseudomonal BL-BLI’s in combination with Fluoroquinolones/aminoglycosides/Glycopeptides.

• Prophylaxis for fungal infections in select cases as per IDSA guidelines

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» This pocket guide is divided into 3 sections: the first part contains a drug dose ready reckoner, the second part has the antibiotic protocols for each infection type and the third part has footnotes along with space for personal notes.

» To use these protocols follow these steps: • Identify the type of infection – Respiratory, intra-abdominal, pneumonia, blood

stream, urinary tract and skin and soft tissue. • Define the location – ICU or ward patient • Accordingly refer to the respective chart. • Identify the patient type based on described parameters – Type 1, 2, 3, or 4 • Refer to the empiric/presumptive therapy column for that patient type. • This will give you the protocol drug to start. • If a column has more than one drug option –

- Choose the drug showing better susceptibility data in the left hand side table OR- Doctor's discretion advised

• Send respective cultures before starting antibiotic therapy • Once culture / sensitivity report available:

- Presumptive therapy antibiotic may require to be changed- Consult Microbiologist / ID physician to decide the choice of antibiotic (based on

narrowest spectrum antibiotic which covers the pathogen isolated) • In all cases physician's discretion is advised based on patient condition

HOW TO USE THE POCKET GUIDE?

Blood Stream Infections (BSI) - ICU Antibiogram

MICROBIOLOGY DATA (n=36)

Most Common Pathogens Prevalance % Antibiotic Sensitivity (%)

Staph aureus (n=20) 55% Linezolid/Vancomycin (100%), Erythromycin (65%), Cefoxitin (30%), Cotrimoxazole (45%), Amoxicillin-Clavulanate (11%)

Pseudomonas (n=8) 22% Polymyxin B/Amikacin (88%), Imipenem/Piperacillin-Tazobactam/Cefoperazone-Sulbactam/Ciprofloxacin (75%), Aztreonam (63%), Ceftazidime (38%)

E. coli (n=6) 17% Imipenem/Cefoperazone-Sulbactam (100%), Piperacillin-Tazobactam (83%), Amikacin (67%), Cefotaxime/Ceftriaxone (50%), Ceftazidime/ Ciprofloxacin (33%)

Salmonella paratyphi A (n=1) 3% Azithromycin/Chloramphinecol/Ceftriaxone (100%)

Acinetobacter (n=1) 3% Polymyxin B/Cefoperazone-Sulbactam (100%)

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Blood Stream Infections (BSI) - IPD Antibiogram



Staph aureus (n=115) 31% Vancomycin (96%), Linezolid (92%), Cefoxitin (80%) Erythromycin (65%), Amoxicillin-Clavulanate (56%), Cotrimoxazole (49%)

E. coli (n=90) 24% Imipenem (93%), Piperacillin-Tazobactam (86%), Cefoperazone-Sulbactam (85%), Amikacin (82%), Ceftriaxone /Cefotaxime/Ciprofloxacin (37%), Ceftazidime (26%)

Pseudomonas (n=82) 22% Piperacillin-Tazobactam (98%), Polymyxin (96%), Imipenem /Cefoperazone-Sulbactam (95%), Amikacin (89%), Ciprofloxacin (65%), Aztreonam (57%), Ceftazidime (45%)

Salmonella typhi & 14% Azithromycin/Chloramphenicol (100%), paratyphi A (n=51) Ceftriaxone (96%)

Acinetobacter (n=34) 9% Polymyxin B (100%), Cefoperazone-Sulbactam (90%), Imipenem (85%), Amikacin (74%), Piperacillin-Tazobactam (70%), Ciprofloxacin (65%), Ceftazidime (29%)

Blood Stream Infections (BSI) - OPD Antibiogram



Salmonella typhi & 53% Azithromycin/Ceftriaxone (100%),paratyphi A (n=26) Chloramphenicol (88%)

Staph aureus (n=8) 16% Vancomycin (88%), Cefoxitin (75%), Cotrimoxazole (71%), Augmentin (50%), Erythromycin (38%)

Pseudomonas (n=7) 14% Polymyxin B/Cefoperazone-Sulbactam (100%), Imipenem/Piperacillin-Tazobactam/Amikacin (86%), Ciprofloxacin (80%), Aztreonam (75%), Ceftazidime (57%)

E. coli (n=6) 12% Imipenem/Piperacillin-Tazobactam/Cefoperazone-Sulbactam (100%), Amikacin (83%), Ceftriaxone /Cefotaxime/Ciprofloxacin (50%)

Acinetobacter (n=2) 4% Polymyxin B (100%), Imipenem/Piperacillin-Tazobactam/Cefoperazone-Sulbactam/ Amikacin/Ciprofloxacin (50%)

Urinary Tract Infections (UTI) - ICU Antibiogram



E.coli (n=22) 49% Imipenem (100%), Amikacin/Nitrofurantoin (60%), Piperacillin-Tazobactam/Cefoperazone-Sulbactam (40%), Cefotaxime/Ciprofloxacin (20%)

Pseudomonas (n=13) 29% Polymyxin B (100%), Imipenem/Piperacillin-Tazobactam/Amikacin (67%), Ciprofloxacin (33%)

Enterococcus (n=7) 16% Vancomycin/Nitrofurantoin (50%)

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Urinary Tract Infections (UTI) - IPD Antibiogram



E.coli (n=228) 54% Imipenem (97%), Nitrofurantoin (87%), Pipercillin-Tazobactam (84%), Amikacin (83%), Cefoperazone-Sulbactam (80%), Cefotaxime (42%)

Enterococcus (n=52) 12% Vancomycin (86%), Nitrofurantoin (84%), Ampicillin (54%), Gentamicin (27%)

Pseudomonas (n=35) 8% Polymyxin B (94%), Imipenem (73%), Amikacin (65%), Piperacillin-Tazobactam (62%), Cefoperazone-Sulbactam (52%), Aztreonam (38%), Ciprofloxacin (36%), Cefoperazone (34%)

Staph aureus (n=13) 3% Linezolid/Vancomycin (100%), Augmentin (63%), Cefoxitin (62%), Erythromycin (50%), Cotrimoxazole (33%)

Proteus (n=12) 3% Imipenem/Piperacillin-Tazobactam (100%), Cefoperazone-Sulbactam/Cefotaxime (83%), Amikacin (82%), Nitrofurantoin (70%), Ceftazidime/Ciprofloxacin (50%)

Urinary Tract Infections (UTI) - OPD Antibiogram



E.coli (n=171) 57% Imipenem (99%), Nitrofurantoin (95%), Piperacillin-Tazobactam (93%), Amikacin (89%), Cefoperazone-Sulbactam (87%), Cefotaxime (55%), Ceftazidime (44%), Ciprofloxacin (37%)

Enterococcus (n=20) 7% Vancomycin (85%), Nitrofurantoin (69%), Ampicillin (63%), Gentamicin (35%)

Pseudomonas (n=16) 5% Polymyxin B (100%), Imipenem (81%), Piperacillin-Tazobactam (63%), Amikacin (50%), Ciprofloxacin (44%), Cefoperazone-Sulbactam/ Cefoperazone (38%), Ceftazidime (25%)

Staph aureus (n=13) 4% Linezolid/Vancomycin (100%), Erythromycin (92%), Amoxicillin-clavulanate (75%), Cefoxitin (69%), Cotrimoxazole (45%)

Proteus (n=5) 2% Imipenem/Piperacillin-Tazobactam/Cefoperazone-Sulbactam/Cefotaxime (100%), Amikacin/ Ceftazidime (80%), Ciprofloxacin (60%), Nitrofurantoin (20%)

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Respiratory / Skin Soft Tissue infections - ICU Antibiogram



Acinetobacter (n=63) 37% Polymyxin B (100%), Imipenem (76%), Cefoperazone-Sulbactam (45%), Piperacillin-Tazobactam (38%), Amikacin (24%)

Pseudomonas (n=32) 19% Polymyxin B (100%), Piperacillin-Tazobactam/ Amikacin (88%), Imipenem (75%), Cefoperazone-Sulbactam (63%), Ciprofloxacin (47%), Aztreonam (42%), Cefoperazone (40%)

E. coli (n=28) 17% Imipenem (100%), Piperacillin-Tazobactam (86%), Cefoperazone-Sulbactam (79%), Amikacin (78%), Cefotaxime/Ceftazidime (35%), Ciprofloxacin (31%)

Klebsiella (n=23) 14% Imipenem (100%), Piperacillin-Tazobactam/ Cefoperazone-Sulbactam/Amikacin (65%), Ciprofloxacin (48%), Cefotaxime (44%), Ceftazidime (35%)

Staph aureus (n=18) 10% Linezolid/Vancomycin (100%), Cefoxitin (61%), Cotrimoxazole (56%), Augmentin/Erythromycin (50%)

Enterococcus (n=5) 3% Linezolid/Vancomycin (100%), Ampicillin (60%), Gentamicin/Erythromycin (40%)

Respiratory / Skin Soft Tissue infections - IPD Antibiogram



Pseudomonas (n=209) 24% Polymyxin B (100%), Piperacillin-Tazobactam (88%), Imipenem (83%), Amikacin (73%), Cefoperazone-Sulbactam (48%), Ciprofloxacin (47%), Cefoperazone(33%)

Staph aureus (n=197) 23% Linezolid/Vancomycin (100%), Cefoxitin (69%), Erythromycin (63%), Augmentin (57%), Cotrimoxazole (52%)

E. coli (n=176) 21% Imipenem (99%), Piperacillin-Tazobactam (82%), Amikacin (77%), Cefoperazone-Sulbactam (75%), Cefotaxime (41%), Ciprofloxacin (28%),Ceftazidime (25%)

Acinetobacter (n=138) 16% Polymyxin B (99%), Imipenem (87%), Piperacillin-Tazobactam (57%), Cefoperazone-Sulbactam (47%), Amikacin (29%)

Klebsiella (n=82) 10% Imipenem (99%), Piperacillin-Tazobactam (85%), Cefoperazone-Sulbactam (80%), Amikacin (74%), Ciprofloxacin (57%), Cefotaxime (49%), Ceftazidime (26%)

Enterococcus (n=51) 6% Linezolid (100%), Vancomycin (98%), Ampicillin (65%), Gentamicin (49%), Erythromycin (38%)

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Respiratory / Skin Soft Tissue infections - OPD Antibiogram



Staph aureus (n=77) 40% Linezolid/Vancomycin (100%), Cefoxitin (91%), Erythromycin (72%), Amoxicillin-Clavulanate (70%), Cotrimoxazole (35%)

Pseudomonas (n=42) 22% Polymyxin B (100%), Piperacillin-Tazobactam (95%), Imipenem (88%), Cefoperazone-Sulbactam/Amikacin (83%), Cefoperazone (70%), Ciprofloxacin (61%), Aztreonam (46%), Ceftazidime (29%)

E. coli (n=26) 14% Imipenem (100%), Piperacillin-Tazobactam /Cefoperazone-Sulbactam/Amikacin (85%), Cefotaxime (54%), Ceftazidime/Ciprofloxacin (31%)

Klebsiella (n=17) 9% Imipenem (100%), Piperacillin-Tazobactam/ Cefoperazone-Sulbactam (82%) Amikacin (76%), Ciprofloxacin (71%), Cefotaxime (65%), Ceftazidime (47%)

Acinetobacter (n=16) 8% Polymyxin B (100%), Imipenem (94%), Piperacillin-Tazobactam (88%), Cefoperazone-Sulbactam (56%), Ciprofloxacin (38%), Amikacin (25%)

Enterococcus (n=13) 7% Vancomycin (100%), Ampicillin (92%), Gentamicin (85%), Erythromycin (46%)

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Blood Stream Infections (BSIs) Antibiotic Protocol: ICU

1. If ESBL +ve Enterobacteriaceae- Deescalate and treat as patient Type 2

2. If Non ESBL/MSSA - De-escalate and Treat as Patient Type 1

Empirically started on Echinocandin / Lip Amp B and Culture shows Candida albicans plus patient is stable -

#De-escalate to Azoles

If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat as Patient type 1

Step down "De-Escalate" Step down "De-Escalate"

If Non ESBL enterobacteriacae / MSSA: Shift to monotherapy if combination used empirically as per the sensitivity report.


1. MDR Pseudomonas / Klebsiella: Colistin + Anti-pseudomonal Beta lactam (pref. Carbapenem) in Extended Infusion) with maximum sensitivity

2. MDR Acinetobacter: Colistin+High dose Sulbactam +/- Carbapenem in Extended Infusion

3. VRSA / VRE : Escalate to Linezolid or Daptomycin

Empirically started on Azole but culture shows Candida species resistant to azoles OR the patient condition deterioates : Escalate to Echinocandin / Lip Amp B / Conv. Amp B based on C/S report and patient condition

Consider Escalation

1. If culture negative & no clinical response within 48 hours of treatment.

2. If culture shows Pseudomonas/Acinetobacter - Treat as Patient type 3

Consider Escalation Consider Escalation


2. If culture is ESBL positive, treat as Patient type 2

Consider Escalation

Patient Type 3 (NI) Patient Type 2 (HCAI)

Hospitalization >5 days ± infections following major invasive procedures


Patient old (> 65 years) + multiple co-morbidities (eg. structural lung disease, immunodeficiency)


± severe sepsis/septic shock

Plus >1 of the following (but not limited to) risk factors for invasive fungal infections: • TPN • Hemodialysis • Immunodeficiency of variable origin • Major abdominal surgery • Multi-focal candida colonization • Diabetes

Recent contact with health care system(hospital / nursing home admission, CAPD) without major invasive procedure


Patient old (> 65 years) with few co-morbidities.

Patient Risk StratificationPatient Type 4 (NI)Patient Type 1 (CAI)

No contact with health care system in last 90 days


Patient young with no or few co-morbid conditions

Presumptive TherapyPresumptive Therapy

Imipenem / Cefoperazone-Sulbactam + Amikacin +/- VancomycinNote: Colistin can be used empirically on Physician's discretion in very sick patients

Hemodynamically stable and no prior exposure to Azoles - FluconazoleHemodynamically Stable + Prior exposure to Azoles - Echinocandins (Caspofungin)/ Lip Amp B / Conv. Amp B (Use Conv Amp B if intolerance or limited availability of other antifungals, with proper administration guidelines/precautions )Hemodynamical ly Unstable - Echinocandins (Caspofungin) / Lip Amp B

Ertapenem OR Piperacillin-Tazobactam +/-AmikacinNote: Vancomycin / Teicoplanin to be used only in MRSA incidence is high


Ceftriaxone OR Amoxicillin-Clavulanate OR Ciprofloxacin* / Ofloxacin*Avoid ciprofloxacin in Patient type 1 since it has potent antipseudomonal activity

Send Samples For Culture Send Samples For Culture Send Samples For Culture Send Samples For Culture

After Culture ReportContinue TreatmentContinue Treatment

1. If the culture is negative & patient responds to clinical treatment

2. If sensitive Pseudomonas / Acinetobacter - Preferably a combination of Antipseudomonal beta-lactam + Aminoglycoside / Antipseudomonal FQ for 3-5 days followed by beta lactam monotherapy for another 5-7 days

3. If MRSA- Shift to Vancomycin / Teicoplanin monotherapy.

If Candida Albicans and patient stable : Continue FluconazoleIf Candida Non-Albicans OR Patient unstable : Continue Echinocandin / Lip Amp B

1. If the pathogen is susceptible to the drug used empirically or culture is negative & patient responds to clinical treatment

2. If ESBL +ve Enterobacteriaceae: Continue treatment with monotherapy as per sensitivity report (Avoid using broad spectrum anti-Pseudomonal drugs)

3. If MRSA/Enterococcus: Use Vancomycin or Teicoplanin Monotherapy

Continue TreatmentContinue Treatment

If the pathogen is sensitive to the drug used empirically or culture is negative & patient responds to clinical treatment

After Culture ReportAfter Culture Report After Culture Report

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Blood Stream Infections (BSIs) Antibiotic Protocol: IPD

1. If ESBL +ve Enterobacteriaceae- Deescalate and treat as patient Type 22. If Non ESBL/MSSA - De-escalate and Treat as Patient Type 1




Step down "De-Escalate"

1. MDR Pseudomonas / Klebsiella: Colistin + Antipseudomonal Beta lactam (pref Carbapenem in Extended Infusion) with maximum sensitivity

2. MDR Acinetobacter: Colistin + High dose Sulbactam +/- Carbapenem in Extended Infusion3. VRSA / VRE : Escalate to Linezolid or Daptomycin

Consider Escalation

1. If culture negative & no clinical response within 48 hours of treatment


Consider Escalation



Consider Escalation








Patient Risk StratificationPatient Type 1 (CAI)





Imipenem / Piperacillin-Tazobactam / Cefoperazone-Sulbactam +/- Vancomycin Ertapenem OR Piperacillin-TazobactamNote: Vancomycin / Teicoplanin to be used only in MRSA incidence is high

Presumptive Therapy

Oral: Cefixime OR Ofloxacin OR Amoxicillin-ClavulanateIV/IM: Ceftriaxone OR Amoxicillin-Clavulanate OR Ciprofloxacin* / Ofloxacin *Avoid ciprofloxacin in Patient type 1 since it has potent antipseudomonal activity

Send Samples For Culture Send Samples For Culture Send Samples For Culture


1. If the culture is negative & patient responds to clinical treatment2. If sensitive Pseudomonas / Acinetobacter - Preferably a combination of Antipseudomonal beta-lactam +

Aminoglycoside / Antipseudomonal FQ for 3-5 days followed by beta lactam monotherapy for another 5-7 days





Continue Treatment


After Culture ReportAfter Culture Report

24 25

Blood Stream Infections (BSIs) Antibiotic Protocol: OPD

If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat as Patient type 1 If Non ESBL enterobacteriacae / MSSA: Shift to monotherapy if combination used empirically as per the sensitivity report.


1. If culture negative & no clinical response within 48 hours of treatment .

2. If culture shows Pseudomonas/Acinetobacter - Treat as Patient type 3 in IPD protocol



Consider EscalationConsider Escalation

Patient Type 2 (HCAI)








Presumptive Therapy

Oral: Cefixime OR Ofloxacin OR Amoxicillin-Clavulanate IV/IM(as OPAT*): Ceftriaxone OR Ertapenem (If ESBLs suspected strongly)

Presumptive Therapy

Oral: Cefixime OR Ofloxacin OR Amoxicillin-ClavulanateIV/IM(as OPAT*): Ceftriaxone OR Ofloxacin OR Amoxicillin-Clavulanate

Send Samples For Culture Send Samples For Culture

After Culture ReportAfter Culture ReportContinue TreatmentContinue Treatment


2. If ESBL +ve Enterobacteriaceae: Continue treatment with monotherapy as per sensitivity rep


26 27

Urinary Tract Infections (UTI) Antibiotic Protocol: ICU



3. If sensitive Enterococcus- A combination of Ampicillin + Gentamicin ( look for synergy test) OR Vancomycin alone

Empirically started on Lip Amp B / Amp B or echinocandin and Culture shows Candida albicans plus

#patient is stable - De-escalate to Azoles

1. If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat as Patient type 1






2. MDR Acinetobacter: Colistin +High dose Sulbactam +/- Carbapenem in Extended Infusion

Empirically started on Azole but culture shows Candida species resistant to azoles OR the patient condition deterioates : Escalate to Lip Amp B / Amp B or Echinocandin based on C/S report and patient condition

Consider Escalation






Consider Escalation
















Imipenem / Piperacillin-Tazobactam / Cefoperazone -Sulbactam + Amikacin Note: Colistin can be used empirically on Physician's discretion in very sick patients

Hemodynamically stable and no prior exposure to Azoles - Fluconazole Hemodynamically Stable + prior exposure to Azoles - Conv. Amp B / Lip Amp BHemodynamically Unstable - Lip Amp B / Conv Amp B / Echinocandins ** (Can use Azoles like Voriconazole as alternative if No prior exposure to azoles) **The urine concentration of Echinocandin is low, therefore they are not preferred therapy for UTI, use only if UTI leads to Candidemia

Ertapenem / Piperacillin-Tazobactam +/- Amikacin


Ceftriaxone / Ofloxacin OR Amikacin / Ertapenem ( If community acquired ESBL producing pathogen)




2. If sensitive Pseudomonas / Acinetobacter - Use Antipseudomonal beta-lactam as per sensitivity either alone or in combination with flouroquino-lone or aminoglycoside

If Candida Albicans and patient stable: Continue FluconazoleIf Candida Non-Albicans OR Patient unstable : Continue Lip Amp B / Amp B or Echinocandin **(**The urine concentration of Echinocandin is low, therefore they are not preferred therapy for UTI, use only if UTI leads to Candidemia )







28 29

Urinary Tract Infections (UTI) Antibiotic Protocol: IPD

1. If ESBL +ve Enterobacteriaceae- Deescalate and treat as patient Type 22. If Non ESBL/MSSA - De-escalate and Treat as Patient Type 13. If sensitive Enterococcus- A combination of Ampicillin + Gentamicin ( look for synergy test) OR Vancomycin

alone

1. If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat as Patient type 1






2. MDR Acinetobacter: Colistin + High dose Sulbactam +/- Carbapenem in Extended Infusion

Consider Escalation



Consider Escalation



Consider Escalation













Imipenem / Piperacillin-Tazobactam +/- Amikacin Note: Colistin can be used empirically on Physician's discretion in very sick patients

Ertapenem / Piperacillin-Tazobactam

Presumptive Therapy

Oral: Norfloxacin OR Cefuroxime / Cefixime OR Amoxicillin-clavulanate OR Nitrofurantoin (If community acquired ESBL Cystitis)IV/IM: Ceftriaxone / Ofloxacin OR Amikacin / Ertapenem ( If community acquired ESBL UTI)



1. If the culture is negative & patient responds to clinical treatment2. If sensitive Pseudomonas / Acinetobacter - Use Antipseudomonal beta-lactam as per sensitivity either alone

or in combination with flouroquinolone or aminoglycoside




Continue Treatment



30 31

Urinary Tract Infections (UTI) Antibiotic Protocol : OPD




2. If culture shows Pseudomonas/Acinetobacter - Treat as Patient type 3 in IPD protocol












Presumptive Therapy

Oral: Cefixime OR Ofloxacin OR Amoxicillin-ClavulanateNote: Can use Nitrofurantoin for ESBL Cystitis

IV/IM (as OPAT): Ceftriaxone OR Ertapenem (if ESBL suspected strongly)

Presumptive Therapy

Oral: Cefixime OR Ofloxacin OR Amoxicillin-ClavulanateNote: Can use Nitrofurantoin for ESBL Cystitis

IV/IM (as OPAT): Ceftriaxone OR Ofloxacin OR Ertapenem (if ESBL suspected strongly)






32 33

Respiratory / Skin Soft Tissue infections Antibiotic Protocol: ICU



Empirically started on Echinocandin / Lip Amp B and Culture shows Candida albicans plus patient is stable -

#De-escalate to Azoles






2. MDR Acinetobacter: Colistin+High dose Sulbactam +/- Carbapenem in Extended Infusion OR Tigecycline (only in SSTI)

3. VRSA / VRE : Escalate to Linezolid / Daptomycin (only in SSTI)

Empirically started on Azole but culture shows Candida species resistant to azoles OR the patient condition deterioates : Escalate to Echinocandin / Lip Amp B / Conv. Amp B based on C/S report and patient condition

Consider Escalation






Consider Escalation
















SSTI and RTI: Imipenem / Piperacillin-Tazobactam / Cefoperazone- Sulbactam + Amikacin/Levofloxacin Note: Colistin can be used empirically on Physician's discretion in very sick patients

Hemodynamically stable and no prior exposure to Azoles - Fluconazole Hemodynamically Stable + prior exposure to Azoles - Echinocandins (Caspofungin)/ Lip Amp B / Conv. Amp B (Use Conv Amp B if intolerance or limited availability of other antifungals, with proper administration guidelines/precautions )Hemodynamically Unstable - Echinocandins (Caspofungin) / Lip Amp B

SSTI : Ertapenem / Piperacillin-Tazobactam + Amikacin Note: Vancomycin / Teicoplanin to be used only in MRSA incidence is highRTI: Piperacillin-Tazobactam / Cefoperazone-Sulbactam +/- Ciprofloxacin / Amikacin


SSTI: Cefazolin/Cefuroxime/Cloxacillin/ Ciprofloxacin* + Metronidazole OR Clindamycin/ Amoxicillin-Clavulanate alone*Avoid ciprofloxacin in Patient type 1 since it has potent anti-pseudomonal activity Note: Source control is must in SSTIs

RTI: Ceftriaxone / Amoxicillin-Clavulanate +/- Macrolide OR Respiratory Flouroquinolone (eg Gemifloxacin, Moxifloxacin)




2. I f sensitive Pseudomonas/Acinetobacter-Preferably a combination of Antipseudomonal beta-lactam + Aminoglycoside / Antipseudo-monal FQ for 3-5 days followed by beta lactam monotherapy for another 5-7 days

3. If MRSA-Shift to Vancomycin/Teicoplanin monotherapy.

If Candida Albicans and patient stable : Continue FluconazoleIf Candida Non-Albicans OR Patient unstable : Continue Echinocandin / Lip Amp B







34 35

Respiratory / Skin Soft Tissue infections Antibiotic Protocol: IPD

1. If ESBL +ve Enterobacteriaceae- Deescalate and treat as patient Type 22. If Non ESBL/MSSA - De-escalate and Treat as Patient Type 1






2. MDR Acinetobacter: Colistin + High dose Sulbactam +/- Carbapenem in Extended Infusion OR Tigecycline (only in SSTI)

3. VRSA / VRE : Escalate to Linezolid / Daptomycin (only in SSTI)

Consider Escalation



Consider Escalation



Consider Escalation













SSTI and RTI:Imipenem / Piperacillin-Tazobactam / Cefoperazone- Sulbactam + Vancomycin +/- Amikacin/Levofloxacin

SSTI and RTI:Ertapenem / Piperacillin-Tazobactam +/- Amikacin /Ciprofloxacin Note: Vancomycin / Teicoplanin to be used only if MRSA incidence is very highMacrolide can be added in RTI

Presumptive Therapy

SSTI: Oral: Amoxycillin- Clavulanate OR Ce f u rox i m e / Ce p h a l e x i n / Ce f a d rox y l + / - MetronidazoleIV/IM: Cefazolin / Cefuroxime / Oxacillin / Ciprofloxacin* +/- Metronidazole OR Amoxicillin-Clavulanate / Clindamycin*Avoid ciprofloxacin in Patient type 1 since it has potent antipseudomonal activity Note: Source control is must in SSTIs

R T I : O ra l : A m ox i c i l l i n - C l av u l a n a te O R Cefpodoxime / Cefdinir +/- Macrolide ( Erythromycin/ Azithromycin) OR Respiratory Flouroquinolone (eg Gemifloxacin, Moxifloxacin)IV/IM: Ceftriaxone OR Amoxicillin-Clavulanate +/- Macrolide



1. If the culture is negative & patient responds to clinical treatment2. If sensitive Pseudomonas / Acinetobacter - Preferably a combination of Antipseudomonal beta-lactam +

Aminoglycoside / Antipseudomonal FQ for 3-5 days followed by beta lactam monotherapy for another 5-7 days





Continue Treatment



36 37

Respiratory / Skin Soft Tissue infections Antibiotic Protocol: OPD



1. If culture negative & no clinical response within 48 hours of treatment.2. If culture shows Pseudomonas/Acinetobacter - Treat as Patient type 3 as in IPD protocol

1. If culture negative & no clinical response within 48 hours of treatment.2. If culture is ESBL positive, treat as Patient type 2










Presumptive Therapy

SSTI:Oral: Amoxycillin- Clavulanate OR Ciprofloxacin +/- MetronidazoleIV/IM (as OPAT): Levofloxacin OR ErtapenemRTI:Oral: Amoxicillin-Clavulanate +/- Macrolide ( Erythromycin/ Azithromycin) OR Respiratory Flouroquinolone (eg Gemifloxacin, Moxifloxacin)IV/IM (as OPAT) : Levofloxacin OR Ertapenem

Presumptive Therapy

SSTI:Oral: Amoxycillin- Clavulanate OR Cefuroxime/ Cephalexin/ Cefadroxyl +/- MetronidazoleIV/IM (as OPAT): Cefazolin / Cefuroxime / Oxacillin +/- Metronidazole OR Amoxicillin-Clavulanate / ClindamycinNote: Source control is must in SSTIsRTI:Oral: Amoxicillin-Clavulanate OR Cefpodoxime / Cefdinir +/- Macrolide ( Erythromycin/ Azithromycin) OR Respiratory Flouroquinolone (eg Levofloxacin, Gemifloxacin, Moxifloxacin)IV/IM (as OPAT) : Ceftriaxone OR Amoxicillin-Clavulanate +/- Macrolide






38

Antibiotic Protocol: OPD1. For treating the Indoor patients, the Microbiology data should be considered mainly for patients belonging to Patient Types 2

and 3. Patient type 1 refers to the patients reporting with Community acquired infections, and for them the treatment options ar2. Avoid Antipseudomonal Fluoroquinolones (e.g.Ciprofloxacin and Levofloxacin) and Antipseudomonal 3rd generation

Cephalosporins (e.g. Ceftazidime and Cefoperazone) in Patients Type 1 and 2 since they have potent antipseudomonal activity3. Treatment of serious infections caused by ESBL +ve pathogens with BL-BLI combinations (eg Piperacillin-Tazobactam,

Cefepime-Tazobactam and Cefoperazone-Sulbactam) should be avoided as there is limited clinical data and evidence available for the use of these drugs in such infections.

4. *OPAT - Out Patient parenteral antibiotic therapy

NOTES

Antibiotic Protocol: ICU1. For treating the Indoor patients, the Microbiology data should be considered mainly for patients belonging to Patient Types 2, 3

and 4. Patient type 1 refers to the patients reporting with Community acquired infections, and for them the treatment options are based on the guidelines.

2. Avoid Antipseudomonal Fluoroquinolones (e.g.Ciprofloxacin and Levofloxacin) and Antipseudomonal 3rd generation Cephalosporins (e.g. Ceftazidime and Cefoperazone) in Patients Type 1 and 2 since they have potent antipseudomonal activity

3. Treatment of serious infections caused by ESBL +ve pathogens with BL-BLI combinations (eg Piperacillin-Tazobactam, Cefepime-Tazobactam and Cefoperazone-Sulbactam) should be avoided as there is limited clinical data and evidence available for the use of these drugs in such infections.

4. In infections with MDR Pseudomonas/ Acinetobacter, Carbapenems should be used as Extended Infusions e.g. Imipenem (2 -3 hrs infusion), Meropenem (3hrs infusion), Doripenem (4hrs infusion)

5. Linezolid and Daptomycin are reserved drugs for inpatients and should be used only in cases of Vancomycin Resistant Staph Aureus (VRSA) or Vancomycin Resistant Enterococci (VRE)

6. # De-escalation to Fluconazole if: Isolates susceptible to Fluconazoie (eg: Candida Albicans) + Patient clinically stable. Deescalation to Voriconazole if : C. Krusei or Voriconazole susceptible C.Glabrata + Patient clinically stable. De-escalation to fluconazole or voriconazole not recommended without confirmation of isolate susceptibility

Antibiotic Protocol: IPD1. For treating the Indoor patients, the Microbiology data should be considered mainly for patients belonging to Patient Types 2

and 3. Patient type 1 refers to the patients reporting with Community acquired infections, and for them the treatment options are based on the guidelines.

2. Avoid Antipseudomonal Fluoroquinolones (e.g.Ciprofloxacin and Levofloxacin) and Antipseudomonal 3rd generation Cephalosporins (e.g. Ceftazidime and Cefoperazone) in Patients Type 1 and 2 since they have potent antipseudomonal activity

3. Treatment of serious infections caused by ESBL +ve pathogens with BL-BLI combinations (eg Piperacillin-Tazobactam, Cefepime-Tazobactam and Cefoperazone-Sulbactam) should be avoided as there is limited clinical data and evidence available for the use of these drugs in such infections.

4. In infections with MDR Pseudomonas/ Acinetobacter, Carbapenems should be used as Extended Infusions e.g. Imipenem (2 -3 hrs infusion), Meropenem (3hrs infusion), Doripenem (4hrs infusion)

5. Linezolid and Daptomycin are reserved drugs for inpatients and should be used only in cases of Vancomycin Resistant Staph Aureus (VRSA) or Vancomycin Resistant Enterococci (VRE)

1. The marker used in our laboratory to assess potential ESBL production among enterobacteriacae is resistance to Cefotaxime and Ceftazidime.

2. The marker used in our laboratory to assess potential MRSA production is the resistance of S. aureus to cefoxitin.

Important PointsImportant Points

COLISTIN The recommended maximum daily dose of colistin is 10 million IU, or 800 mg of colistimethate sodium, from the manufacturer of Coly-Mycin M, which is approximately double the recommended daily dose from the manufacturer of ColomycinColy-Mycin M Parenteral should be given in 2 to 4 divided doses at dose levels of 2.5 to 5 mg/kg per day for patients with normal renal function, depending on the severity of the infection.

IMIPENEM/CILASTATIN Maximum dose is 50mg/kg/day or 4 grams/day, whichever is lowest . Give in divided doses

MEROPENEM 2 g every 8 h.

ERTAPENEM 1gm/day

PIPERACILLIN / The usual total daily dose of Piperacillin and Tazobactam for injection for adults is 3.375 gTAZOBACTAM every six hours totaling 13.5 g (12 g piperacillin/1.5 g tazobactam). presumptive treatment

of patients with nosocomial pneumonia should start with Piperacillin and Tazobactam for injection at a dosage of 4.5 g every six hours plus an aminoglycoside, totaling 18 g (16 g piperacillin/2 g tazobactam). For patients on hemodialysis, the maximum dose is 2.25 g every twelve hours for all indications other than nosocomial pneumonia and 2.25 g every eight hours for nosocomial pneumonia. max dose 4.5 gm tds Paediatric (Intravenous) Dose:300 mg/kg/day in 3-4 divided doses, max: 4g tds.

AMPICILLIN/SULBACTAM The recommended adult dosage of ampicillin and sulbactam for injection is 1.5 g (1 g ampicillin as the sodium salt plus 0.5 g sulbactam as the sodium salt) to 3 g (2 g ampicillin as the sodium salt plus 1 g sulbactam as the sodium salt) every six hours. This 1.5 to 3 g range represents the total of ampicillin content plus the sulbactam content of ampicillin and sulbactam for injection, and corresponds to a range of 1 g ampicillin/0.5 g sulbactam to 2 g ampicillin/1 g sulbactam. The total dose of sulbactam should not exceed 4 grams per day.

CEFOPERAZONE/ In severe or refractory infections the daily dosage of sulbactam/cefoperazone may beSULBACTAM increased up to 8 g of the 1:1 ratio (i.e., 4 g cefoperazone activity maximum dosage is

4g/day.). Patients receiving the 1:1 ratio may require additional cefoperazone administered separately. Doses should be administered every 12 hours in equally divided doses. The recommended maximum daily dosage of sulbactam is 4 g.

TIGECYCLINE Adults IV Maximum 100 mg daily.

CEFTRIAXONE The total daily dose should not exceed 4 g.

CEFUROXIME 1.5 g tds

CIPROFLOXACIN IV maximum total daily dose 1200 mg

MOXIFLOXACIN 400 mg orally or IV q24h

LINEZOLID Maximum adult dose: 600 mg IV or orally every 12 hours

VANCOMYCIN maximum: 2gm/dose Higher total daily doses of vancomycin have been associated with nephrotoxicity

METRONIDAZOLE IV max: 500 mg tds

AMIKACIN The total daily dose by all routes of administration should not exceed 15 mg/kg/day.

CEFTAZIDIME Maximum dose 12 g/day

CEFIXIME The recommended dose of cefixime is 400 mg once daily

AZTREONAM 8 grams/day.

Antibiotic Maximum Daily Dose

Maximum Daily Dose of Antibiotics

41

The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable, intravenous delivery systems.

Ÿ Use aseptic technique to avoid contamination of sterile injection equipment.

Ÿ Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient or to access a medication or solution that might be used for a subsequent patient.

Ÿ Use fluid infusion and administration sets (i.e. intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set.

Ÿ Use single-dose vials for parenteral medications whenever possible.

Ÿ Do not administer medications from single-dose vials or ampoules to multiple patients or combine leftover contents for later use.

• If multi-dose vials must be used, both the needle or cannula and syringe used to access the multi-dose vial must be sterile.

• Do not keep multi-dose vials in the immediate patient treatment area. Store in accordance with the manufacturer’s recommendations and discard if sterility is compromised or questionable.

• Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.

• Infection control practices for special lumbar puncture procedures: Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture, and spinal or epidural anesthesia.

• Worker safety: Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogens (see OSHA Bloodborne Pathogens Standard CFR 1910.1030 and Needlestick Safety and Prevention Act on the OSHA website at http://www.osha.gov/SLTC/bloodbornepathogens/index.htm

Safe Injection PracticesFrom the CDC Healthcare Infection Control Practices Advisory CommitteeGuideline for Isolation Precautions: Preventing Transmission of Infectious

Agents in Healthcare Settings, 2007

42

REMEMBERImproper use of syringes, needles,and medication vials can result in

transmission of life-threatening infections to patients

notification of patients of possible exposure to bloodborne pathogens and recommendations that they be tested for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus

referral of providers to licensing boards for disciplinary action

malpractice suits filed by patients

43

Antibiotic Summary Chart

44

Penicillin Gram+cocci bactericidal Inhibits cell wall AllergyPenicillin G and Some anaerobes synthesisPenicillin V

Penicillin Staphylococci bactericidal Inhibits cell wall AllergyPenicillinaseResistantPenicillins

Penicillin Gram+cocci bactericidal Inhibits cell wall AllergyAminopenicillins Some Gram - bacilli synthesis

Penicillin Gram + cocci bactericidal Inhibits cell wall AllergyAntipseudomonal gram+bacilli synthesisand Extended- Pseudomonas sp.SpectrumPenicillins

Carbapenem Gram+species bactericidal Inhibits cell wall AllergyImipenem Gram+species synthesisErtapenem Anaerobes

Monobactam Gram-bacilli bactericidal Inhibits cell wall N AAztreonam synthesis

Cephalosporin First Gram+cocci bactericidal Inhibits cell wall AllergyGeneration- eg.: Some Gram-bacilli synthesiscefazolin, cephalexin

Cephalosporin Gram+cocci bactericidal Inhibits cell wall AllergySecond-Generation Gram+bacilli synthesiseg: Cefuroxime Some anaerobes

Cephalosporin Many Gram-bacilli bactericidal Inhibits cell wall AllergyThird-Generation Pseudomonas sp. synthesiseg: ceftriaxone, ceftazidimeFourth-Generation-eg: cefepime

Aminoglycosides Gram-bacilli bactericidal Inhibits bacerial • Nephrotoxicityoprotein synthesis • Ototoxicity

Quinolones Gram-bacilli bactericidal Inhibits DNA • CNS reactionsSecond- Staphylococcus sp. gyrase • PhotosensitivityGeneration Atypical organisms • Developmental

bone/joint lesions

Antibiotics Major Spectrum Bactericidal or Mechanism Major Adverseof Acitivity Bacteriostatic of Action Reactions

Quinolones Gram-bacilli bactericidal Inhibits DNA • CNS reactionsSecond- Staphylococcus sp. gyrase • PhotosensitivityGeneration Streptococcus sp. • Developmental

Atypical organisms bone/joint lesions

Macrolides Gram+/Gram-cocci bacteriostatic Inhibits bacterial • well tolerateeg: azithromycin Some Haemophllus sp. protein synthesis • Some GI

Atypical organisms intolerance

Tetracyclines Gram+/Gram- bacteriostatic Inhibits bacterial • GI intoleranceaerobes & anaerobes protein synthesis • PhotosensitivityAtypical organisms • Developmental

tooth staining

Co-trimoxazole Gram+/ Gram- bactericidal Inhibits Formation • GI intoleranceorganisms of vital metabolic • CNS effects

compound • Skin rash• Hematologic reactions

Glycopeptides Staphylococcus sp. bactericidal Inhibits cell wall • Skin rasheg: Vancomycin Streptococcus sp. bacteriostatic synthesis • nephrotoxicity

Enterococci vs. enterococci • Otoloxicity

Antibiotics Major Spectrum Bactericidal or Mechanism Major Adverseof Acitivity Bacteriostatic of Action Reactions

Antibiotic Summary Chart

45

IRRATIONAL/LESS EVIDENCE BASED ANTIBIOTICS

1. Amoxicllin - tazobactam

2. Cefadroxil-clavulanic acid

3. Cefepime + Amikacin

4. Cefepime-sulbactam

5. Cefepime-tazobactam

6. Cefixime + Ofloxacin

7. Cefixime + Ornidazole

8. Cefixime-clavulanic acid

9. Cefotaxime-sulbactam

10. Cefpodoxime-clavulanic

11. Ceftazidime-tazobactam

12. Ceftriaxone-sulbactam

13. Ceftriaxone-tazobactam

14. Cefuroxime-clavulanic acid

15. Cefuroxime-sulbactam

16. Meropenem-sulbactam

17. Vancomycin + Ceftriaxone

18. Cefoperazone –Tazobactam

19. Ampicilin-Amoxicilin-Cloxacillin

20. Ceftazidime-Sulbactam

21. Ofloxacin- Ornidazole/Tinidazole

22. Gatifloxacin-Ornidazole

23. Fluconazole-Tinidazole

24. Doxycycline-Tinidazole

25. Tetracycline-Metronidazole

26. Cefixime/Cefadroxil + Ambroxol + Lactobacillus

27. Ciprofloxacin/Gatifloxacin + Ambroxol

28. Roxithromycin + Ambroxol

46

CATEGORIZATION OF ANTIBIOTICS

Restricted use

A pre use authorisation from an ID Physician / Clinical Microbiologist needs to be taken before prescribing these antibiotics. A written documentation to be maintained which captures the request along with justification for use by the clinician and also captures the approval for use by the authority in charge

Limited access

Unrestricted use of these antibiotics may be allowed for empirical use for first 48-72hrs but after that a clinical justification by clinician and approval from authority in charge needs to be documented that why these antibiotics cannot be de-escalated and need to be continued further

Under Surveillance

A close monitoring to check their usage (indication, quantity and pattern) in OPD / Type 1 Patients/ Surgical prophylaxis. Audits to be done at regular intervals to assess their consumption

47

RESTRICTED USE ANTIBIOTICS: WHAT AND WHY ?

Colistin: It is the last resort for managing gram negative MDRs and its use, dose and duration needs to be rationalised. Liberal use should be restricted

Doripenem: It is the last carbapenem (at least in near future). If Imipenem and Meropenem are working, we need to conserve the use of Doripenem

Rifampicin: (For Non-TB use) This is a valuable drug for TB. The use of rifampicin in MDR Pseudomonas, Acinetobacter or MRSA should be restricted

Linezolid: Alternatives available eg. Vancomycin/Teicoplanin. Linezolid is bacteriostatic and available as oral - more prone for misuse VRSA / VRE rare

Daptomycin: Alternatives are available for MRSA eg. Vancomycin and Teicoplanin. Moreover VRSA and VRE are still not a major cause of concern

Tigecycline: Bacteriostatic, one of the most Broad spectrum drugs, has limited role in MDR infections like SSTI, IAI where ESBL/MRSA and or Acinetobacter are feared.

Sulbactam: Recently introduced in market. Reserved for PDR Acinetobacter. Dose has to be correct (4-12gm/day for PDR Acinetobacter)

48

LIMITED ACCESS ANTIBIOTICS: WHAT AND WHY?

Imipenem/Meropenem : Use as empirical in sick patients is allowed looking at the antibiograms in most hospitals showing better sensitivity of these antibiotics over other classes, however after culture and sensitivity report is available, if it shows a susceptible pathogen to other classes of ABs plus if patient condition improves - then de-escalation should be advised.

Piperacillin-Tazobactam/Cefoperazone-Sulbactam: These are as broad spectrum as carbapenems (this fact is not appreciated generally). Use as empirical in sick patients is allowed looking at the antibiograms in most hospitals showing decent sensitivity of these antibiotics over other classes, however after culture and sensitivity report is available, if it shows a susceptible pathogen to other classes of antibiotics plus if patient condition improves - then de-escalation should be advised.

Vancomycin/Teicoplanin: Use as empirical in sick patients may be allowed specially in BSI, SSTI where MRSA is suspected but if after 48-72hrs culture and sensitivity report shows no staph aureus or MSSA then Vanco/Teico have absolutely no role and should be discontinued.

49

UNDER SURVEILLANCE ANTIBIOTICS: WHAT AND WHY?

3rd generation cephalosporins (both oral and IV) and Flouroquinolones:

One of the main reasons for widespread ESBLs in India in the community is due to overuse of 3rd gen ceph and flouroquinolones at OPD level-Type 1 patients , pediatric patients and Surgical prophylaxis.

It is must to educate the clinicians about these antibiotics and the collateral damage they cause. Also it is imperative to exercise control on liberal usage of these antibiotics in a phased manner and perform regular audits on the rate of consumption of these antibiotics. This could be the single most valuable intervention to curb resistance in India in community

NOTES

50

Christian Medical CollegeLudhiana, Punjab (INDIA)Tel:+91-161-5026999; 5010925; 5010924Fax:+91-161-2228416; 5010815Web: www.cmcludhiana.org

CMC Ludhiana exists to:

Ÿ Provide Excellence in medical care

Ÿ Serve the health needs of the community including the underprivileged.

Ÿ Train health professionals for India

Ÿ Provide wholistic healing (body, spirit and soul) in the spirit of Jesus Christ.

CMC’s Motto:

“My Work is for a King”“My Work is for a King”Dr. Edith Mary Brown

Founder of CMC Ludhiana

guidelines for antimicrobial therapy - …cmcludhiana.in/cmc-hospital-antibiotic-policy2012.pdf ·...

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