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TRANSCRIPT
Trust Guideline for
Antimicrobial Agents in Adults
(Antibiotic Guidelines)
A guideline recommended for use
In All areas except Childrens Services and Mount Vernon Cancer Centre
By Doctors Pharmacists and Nurses involved in prescribingsupplyingadministering antimicrobials
For All non-pregnant adult patients (ie aged 16yrs and over) in East amp North Hertfordshire NHS Trust (except Mount Vernon Cancer Centre)
Key Words Antimicrobial agents antibiotics treatment infection prophylaxis gentamicin
Written by Dr Saba Qaiser (Consultant Microbiologist)
Dr Sumita Pai (Consultant Microbiologist)
Dr Vrinda Shet (Consultant Microbiologist)
Ana Patricio (Antimicrobial Pharmacist)
Approved by Therapeutics Policy Committee
Dr Adie Viljoen (Chair)
11th October 2017
Trust ratified
Jacqui Evans
4th December 2017
To be reviewed before December 2020
To be reviewed by Chair of the Trustrsquos Antimicrobial Forum
Guideline supersedes Version 16 of this Guideline
CGSG Guideline Registration No 008 Version No 17
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 2 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Dissemination and Access This Guideline can only be considered valid when viewed via the East amp North Hertfordshire NHS Trust Knowledge Centre If this document is printed in hard copy or saved at another location you must check that it matches the version on the Knowledge Centre
Equality Impact Assessment This Guideline and its impact upon equality has been reviewed in line with the Trustrsquos Equality Scheme and no detriment was identified
Associated Documentation
Antimicrobial Agents in Neonates (Antibiotic Guidelines)
Neonatal Antibiotic Policy
CP 187 Antimicrobials for Renal Patients
CGSG 058 Childrenrsquos Antibiotic Guideline (Antimicrobial Agents in Children)
CP102 Trust Policy for The Prevention and Management of Clostridium difficile Infection (P 18)
Trust Policy for Gentamicin Dosing and Monitoring for Adults
CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
Caesarean Section Guideline no 427
Review This document will be reviewed within three years of issue or sooner in light of new evidence Version Control
Version No Issue Date Reasons for Production or Revision
15 Feb 2016
Amendment of teicoplanin doses and teicoplanin appendix added Amendment of severe CAP recommendation New surgical prophylaxis recommendation for bone surgery and prosthetic joint surgery Removal of gentamicin dose recommendations and link to Trust Policy for Gentamicin Dosing and Monitoring for Adults made Penicillin allergy poster updated Antimicrobial pharmacist name and bleep number update List of authors amended
16 June 2017
Updated respiratory guideline
Alternatives to piperacillin-tazobactam during supply shortage
Antibiotic prophylaxis for permanent pacemaker insertion updated
17 Nov 2017
Uncomplicated UTI in pregnancy
CAP CURB 65 1
Neutropenic sepsis guideline update
Caesarean Section prophylaxis Guideline no 427 hyperlink
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 3 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Contents
Section Page
1 Introduction and General Principles 4
2 Useful Telephone Numbers 7
3 Restricted Antibiotics 8
4 Conditions and Recommended Treatment 9
Skin and Soft Tissue Infections 9
Urinary Tract Infections 13
Respiratory Tract Infections 14
GastrointestinalIntra-abdominal Infections 30
Central Nervous System Infections 34
Bone and Joint Infections 35
Endocarditis 36
Septicaemia (including Neutropenic Sepsis) 37
ENT (Oropharyngeal) Infections 39
Ophthalmic Infections 40
Genitourinary Tract InfectionsSexually Transmitted Diseases 41
5 Antibiotic Prophylaxis for Surgery 43
GastrointestinalIntra-abdominal 44
Genitourinary 45
Obstetric amp Gynaecological 46
Plastic and Reconstructive 46
Orthopaedic 47
Vascular Surgery 48
Thoracic Surgery amp Head amp Neck Surgery 48
6 Other Antibiotic Prophylaxis 49
7 Further reading 50
Appendix 1 Guideline for Switch Antibiotic Therapy 51
Appendix 2 Penicillin Allergy and Poster General Points on Allergies 53
Appendix 3 Protocol for Vancomycin Administration in Adults 55
Appendix 4 Teicoplanin dose banding in adults with good renal function 56
Appendix 5 Extended Interval Gentamicin Dosing 59
Appendix 6 Extended Interval Amikacin Dosing 60
Appendix 6a Calculation of Corrected Body Weight (CBW) for Dosing in Obese Patients
63
8 Further reading 64
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 4 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
1 INTRODUCTION
This document is the Trustrsquos Guideline for the use of antibiotics If deviation from this Guideline
is clinically indicated a Consultant Microbiologist must be informed to assess the need and to authorise any deviation agreed to be necessary
This Guideline is for antibiotic use in non-pregnant adults (ie aged 16 years and over) with normal renal and liver function unless specifically stated All doses given therefore assume normal renal function If renal function is impaired please discuss appropriate dosing with the Pharmacist
For pregnant women children and neonates please refer to the appropriate Guidelines on the Knowledge Centre
Sections of this Guideline may be revised in times of outbreaks or drug shortages
General Principles of Antimicrobial Prescribing
Avoid unnecessary antibiotic use
Antibiotics have harmful effects eg allergy toxicity superinfection (eg Clostridium difficile colitis) and the generation of microbial resistance in the individual and the community at large
Appropriate microbiological samples must be taken before starting antibiotic therapy
A microbiological diagnosis is vital for optimal treatment of severe infections such as meningitis osteomyelitis endocarditis and septicaemia
Effective therapy should be commenced promptly in patients with life-threatening infection
When there is a critical need eg clinical diagnosis of meningococcal disease antibiotic therapy should be started without delay Prescribing should be in accordance with this Guideline which takes account of local resistance patterns Deviations from this Guideline should be discussed with the Consultant Microbiologist
Consider patient-specific factors when prescribing antibiotics
Choice of initial (or empirical) antibiotics will depend on whether the infection is hospital or community acquired severity site of infection colonisation with multi-resistant organisms recent antibiotic history immune-competence pregnancy allergies and drug interactions
All antibiotics should be clearly prescribed giving dosage frequency and duration
The dedicated antimicrobial section of the drug chart should be used for all antibiotic prescriptions with the exception of gentamicin and amikacin The diagnosisreason for antimicrobial therapy and anticipated duration of therapy should be clearly documented in the patientrsquos medical notes AND on the drug chart
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 5 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Use oral antibiotics whenever possible in preference to intravenous antibiotics
Intravenous therapy can be given at a much higher dose achieve higher drug concentration in blood and tissue and is more reliably absorbed than oral antibiotics However it has important disadvantages such as the risk of super infections (eg cannula-related wound infection and septicaemia) and greater expense Therefore the intravenous route should be reserved for patients with severe infections threatening life or major disability (eg endocarditis meningitis and septicaemia) patients who cannot tolerate or absorb oral medication or when no oral antibiotic alternative is available
Surgical prophylaxis should be administered as a single IV dose
Where antibiotics have been shown to be effective for surgical prophylaxis they should be given as a single dose 30 minutes prior to incision With the exceptions given in this Guideline (ie prolonged surgery gt5hr significant blood loss gt15L prosthetic implant surgery) further prophylactic doses are not indicated (See pages 41 ndash 46)
Antimicrobial Review and Stewardship
All antibiotics should be reviewed daily and the review documented in the patientrsquos medical notes
In particular the patient should be reviewed at 48 hrs and again at 5 days in
conjunction with culture results and then a clinical decision made and documented re whether to
Stop antibiotics (no evidence of infection)
Switch from intravenous to oral therapy (refer to the Guideline for Switch Antibiotic Therapy ndash see Appendix 1)
Change antibiotics (de-escalate switch or substitute based on culture results amp other investigations)
Continue (review again after a further 24 hours)
Refer to OPAT (Outpatient Parenteral Antibiotic Therapy)
The total duration of antibiotics should not normally exceed 5 to 7 days for acute infections
Cautions to Antimicrobial Prescribing
Clostridium difficile
The following antibiotic classes are strongly associated with C difficile infection and pseudomembranous colitis Cephalosporins Ciprofloxacin and Clindamycin Use of these antibiotics is strictly restricted They should ONLY be used for the specific indications in this Guideline OR upon the advice of the Consultant Microbiologist
With the exceptions given in this Guideline surgical prophylaxis should be single dose and should NOT continue after surgery Antibiotics continued after surgery have been shown to increase C difficile infection 3 times without any further reduction in infection
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 6 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Multi-resistant organisms
Use of antibiotics in patients colonised or infected with meticillin resistant Staphylococcus aureus (MRSA) vancomycin resistant enterococci (VRE) or multi-resistant coliforms requires careful consideration of the predicted benefit of antibiotics against the potential disadvantages and also of the choice of antibiotic agent
Advice of a Consultant Microbiologist should always be sought prior to the initiation of such antibiotic courses
Prescribing in penicillin allergic patients
General guidance on appropriate antibiotics to use in the penicillin allergic patient is included at the end of this document (See Appendix 2)
A careful and thorough allergy history is important to differentiate true penicillin allergy from drug intolerance and other reactions (ie what was the reaction when was it to which drug) True penicillin allergy only occurs in 7 ndash 23 of those who give a history
Within this Guideline
Drugs in RED are contraindicated in penicillin allergy
Drugs in ORANGE should be prescribed with caution They may be appropriate for a mild allergy (eg rash delayed reaction) but should not be prescribed for patients with severe penicillin allergy (eg anaphylaxis angioedema) or cephalosporin allergy
Drugs in GREEN are considered safe in penicillin allergy Please note that a patient with penicillin allergy is three times more likely to react to ANY drug owing to the atopic nature of the condition
Therapeutic Drug Monitoring
Drugs such as vancomycin teicoplanin and the aminoglycosides (eg gentamicin amikacin) require careful monitoring of drug levels This is of particular importance when there is renal impairment (See Appendices 3 4 5 and 6 and Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Use of a once ndash daily dose of gentamicin is now adopted in the Trust for serious Gram negative sepsis When this method of gentamicin administration is considered the Trust Policy for Gentamicin Dosing and Monitoring for Adults should be adhered to
NB When in doubt about any aspect of the use of antibiotics always ask a Consultant
Microbiologist for advice
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 7 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 USEFUL TELEPHONE NUMBERS Microbiology Laboratory This department has now moved to Cambridge University Hospitals NHS Trust and is based at Addenbrookersquos Hospital For urgent results call 01223 257037
For queries around samples contact The Pathology Partnership (TPP) via email between 0800
and 2000 at thepartnershelpdesknhsnet or call 0333 1032220
NB Always telephone the laboratory at Lister on ext 4694 when sending urgent
specimens that require immediate processing Consultants Between 9am ndash 5pm Monday ndash Friday
The Consultant Microbiologist taking telephone enquiries during the day may be contacted via the daytime Microbiology mobile (07500 975834)
Out of hours (including weekends Bank Holidays)
Contact the Consultant Medical Microbiologist on call via hospital switchboard This is also the route for contacting the on-call Biomedical Scientist
Antimicrobial Pharmacist bleep 5933 Other Numbers
Public Health England 0300 303 8537 (Notification of infectious diseases)
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 8 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
3 RESTRICTED ANTIBIOTICS
A number of antibiotics are restricted and should ONLY be used for the indications outlined in the following chapters OR with input from a Consultant Microbiologist The list includes the following agents Quinolones (ciprofloxacin and levofloxacin)
Glycopeptides (vancomycin and teicoplanin)
Aminoglycosides (gentamicin amikacin streptomycin)
Cephalosporins (eg cefuroxime)
Carbapenems (imipenem meropenem and ertapenem)
Colistin (nebulisedintravenous)
Piperacillintazobactam
Temocillin
Fosfomycin (except Urology)
Rifampicin (except by Respiratory Team for TB)
Azithromycin
Tigecycline
Daptomycin
Linezolid If any of the above are prescribed for an indication outside this Guideline the Ward Pharmacist will contact the prescriber and a Consultant Microbiologist to ensure they are authorised for use Where these antibiotics are held as stock in defined areas (eg Theatres ITU Renal) they must not be supplied to other wards or clinical areas without the authorisation of a Consultant Microbiologist Out of hours the Duty Matron will not supply a restricted antimicrobial agent from the emergency drug cupboard or authorise its ldquoloanrdquo from a defined area other than for a use outlined in this Guideline without the approval of a Consultant Microbiologist The Emergency Duty Pharmacist will not attend to supply a restricted antimicrobial agent without the authorisation of a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 9 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections
Infection Category Antimicrobials Comments
Cellulitis
Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus
Duration 7 ndash 10 days
Discuss with Consultant Microbiologist if no response after 72 hours
There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)
Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist
Mild (penicillin allergy)
Clarithromycin 500mg bd PO
Mild (MRSA colonised)
Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive
Severe Flucloxacillin 1 ndash 2g qds IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Cellulitis due to IV cannula
Remove cannula and manage as for lsquoCellulitisrsquo
Leg Ulcers pressure sores (non-diabetic)
No clinical evidence of
infection No antibiotics required
Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo
Surgical wound infection (Clean surgery)
Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus
Surgical wound infection (contaminated
abdomino-pelvic surgery)
Mild Manage as for lsquoCellulitisrsquo
Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection
Severe Co-amoxiclav 12g TDS IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 2 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Dissemination and Access This Guideline can only be considered valid when viewed via the East amp North Hertfordshire NHS Trust Knowledge Centre If this document is printed in hard copy or saved at another location you must check that it matches the version on the Knowledge Centre
Equality Impact Assessment This Guideline and its impact upon equality has been reviewed in line with the Trustrsquos Equality Scheme and no detriment was identified
Associated Documentation
Antimicrobial Agents in Neonates (Antibiotic Guidelines)
Neonatal Antibiotic Policy
CP 187 Antimicrobials for Renal Patients
CGSG 058 Childrenrsquos Antibiotic Guideline (Antimicrobial Agents in Children)
CP102 Trust Policy for The Prevention and Management of Clostridium difficile Infection (P 18)
Trust Policy for Gentamicin Dosing and Monitoring for Adults
CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
Caesarean Section Guideline no 427
Review This document will be reviewed within three years of issue or sooner in light of new evidence Version Control
Version No Issue Date Reasons for Production or Revision
15 Feb 2016
Amendment of teicoplanin doses and teicoplanin appendix added Amendment of severe CAP recommendation New surgical prophylaxis recommendation for bone surgery and prosthetic joint surgery Removal of gentamicin dose recommendations and link to Trust Policy for Gentamicin Dosing and Monitoring for Adults made Penicillin allergy poster updated Antimicrobial pharmacist name and bleep number update List of authors amended
16 June 2017
Updated respiratory guideline
Alternatives to piperacillin-tazobactam during supply shortage
Antibiotic prophylaxis for permanent pacemaker insertion updated
17 Nov 2017
Uncomplicated UTI in pregnancy
CAP CURB 65 1
Neutropenic sepsis guideline update
Caesarean Section prophylaxis Guideline no 427 hyperlink
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 3 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Contents
Section Page
1 Introduction and General Principles 4
2 Useful Telephone Numbers 7
3 Restricted Antibiotics 8
4 Conditions and Recommended Treatment 9
Skin and Soft Tissue Infections 9
Urinary Tract Infections 13
Respiratory Tract Infections 14
GastrointestinalIntra-abdominal Infections 30
Central Nervous System Infections 34
Bone and Joint Infections 35
Endocarditis 36
Septicaemia (including Neutropenic Sepsis) 37
ENT (Oropharyngeal) Infections 39
Ophthalmic Infections 40
Genitourinary Tract InfectionsSexually Transmitted Diseases 41
5 Antibiotic Prophylaxis for Surgery 43
GastrointestinalIntra-abdominal 44
Genitourinary 45
Obstetric amp Gynaecological 46
Plastic and Reconstructive 46
Orthopaedic 47
Vascular Surgery 48
Thoracic Surgery amp Head amp Neck Surgery 48
6 Other Antibiotic Prophylaxis 49
7 Further reading 50
Appendix 1 Guideline for Switch Antibiotic Therapy 51
Appendix 2 Penicillin Allergy and Poster General Points on Allergies 53
Appendix 3 Protocol for Vancomycin Administration in Adults 55
Appendix 4 Teicoplanin dose banding in adults with good renal function 56
Appendix 5 Extended Interval Gentamicin Dosing 59
Appendix 6 Extended Interval Amikacin Dosing 60
Appendix 6a Calculation of Corrected Body Weight (CBW) for Dosing in Obese Patients
63
8 Further reading 64
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 4 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
1 INTRODUCTION
This document is the Trustrsquos Guideline for the use of antibiotics If deviation from this Guideline
is clinically indicated a Consultant Microbiologist must be informed to assess the need and to authorise any deviation agreed to be necessary
This Guideline is for antibiotic use in non-pregnant adults (ie aged 16 years and over) with normal renal and liver function unless specifically stated All doses given therefore assume normal renal function If renal function is impaired please discuss appropriate dosing with the Pharmacist
For pregnant women children and neonates please refer to the appropriate Guidelines on the Knowledge Centre
Sections of this Guideline may be revised in times of outbreaks or drug shortages
General Principles of Antimicrobial Prescribing
Avoid unnecessary antibiotic use
Antibiotics have harmful effects eg allergy toxicity superinfection (eg Clostridium difficile colitis) and the generation of microbial resistance in the individual and the community at large
Appropriate microbiological samples must be taken before starting antibiotic therapy
A microbiological diagnosis is vital for optimal treatment of severe infections such as meningitis osteomyelitis endocarditis and septicaemia
Effective therapy should be commenced promptly in patients with life-threatening infection
When there is a critical need eg clinical diagnosis of meningococcal disease antibiotic therapy should be started without delay Prescribing should be in accordance with this Guideline which takes account of local resistance patterns Deviations from this Guideline should be discussed with the Consultant Microbiologist
Consider patient-specific factors when prescribing antibiotics
Choice of initial (or empirical) antibiotics will depend on whether the infection is hospital or community acquired severity site of infection colonisation with multi-resistant organisms recent antibiotic history immune-competence pregnancy allergies and drug interactions
All antibiotics should be clearly prescribed giving dosage frequency and duration
The dedicated antimicrobial section of the drug chart should be used for all antibiotic prescriptions with the exception of gentamicin and amikacin The diagnosisreason for antimicrobial therapy and anticipated duration of therapy should be clearly documented in the patientrsquos medical notes AND on the drug chart
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 5 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Use oral antibiotics whenever possible in preference to intravenous antibiotics
Intravenous therapy can be given at a much higher dose achieve higher drug concentration in blood and tissue and is more reliably absorbed than oral antibiotics However it has important disadvantages such as the risk of super infections (eg cannula-related wound infection and septicaemia) and greater expense Therefore the intravenous route should be reserved for patients with severe infections threatening life or major disability (eg endocarditis meningitis and septicaemia) patients who cannot tolerate or absorb oral medication or when no oral antibiotic alternative is available
Surgical prophylaxis should be administered as a single IV dose
Where antibiotics have been shown to be effective for surgical prophylaxis they should be given as a single dose 30 minutes prior to incision With the exceptions given in this Guideline (ie prolonged surgery gt5hr significant blood loss gt15L prosthetic implant surgery) further prophylactic doses are not indicated (See pages 41 ndash 46)
Antimicrobial Review and Stewardship
All antibiotics should be reviewed daily and the review documented in the patientrsquos medical notes
In particular the patient should be reviewed at 48 hrs and again at 5 days in
conjunction with culture results and then a clinical decision made and documented re whether to
Stop antibiotics (no evidence of infection)
Switch from intravenous to oral therapy (refer to the Guideline for Switch Antibiotic Therapy ndash see Appendix 1)
Change antibiotics (de-escalate switch or substitute based on culture results amp other investigations)
Continue (review again after a further 24 hours)
Refer to OPAT (Outpatient Parenteral Antibiotic Therapy)
The total duration of antibiotics should not normally exceed 5 to 7 days for acute infections
Cautions to Antimicrobial Prescribing
Clostridium difficile
The following antibiotic classes are strongly associated with C difficile infection and pseudomembranous colitis Cephalosporins Ciprofloxacin and Clindamycin Use of these antibiotics is strictly restricted They should ONLY be used for the specific indications in this Guideline OR upon the advice of the Consultant Microbiologist
With the exceptions given in this Guideline surgical prophylaxis should be single dose and should NOT continue after surgery Antibiotics continued after surgery have been shown to increase C difficile infection 3 times without any further reduction in infection
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 6 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Multi-resistant organisms
Use of antibiotics in patients colonised or infected with meticillin resistant Staphylococcus aureus (MRSA) vancomycin resistant enterococci (VRE) or multi-resistant coliforms requires careful consideration of the predicted benefit of antibiotics against the potential disadvantages and also of the choice of antibiotic agent
Advice of a Consultant Microbiologist should always be sought prior to the initiation of such antibiotic courses
Prescribing in penicillin allergic patients
General guidance on appropriate antibiotics to use in the penicillin allergic patient is included at the end of this document (See Appendix 2)
A careful and thorough allergy history is important to differentiate true penicillin allergy from drug intolerance and other reactions (ie what was the reaction when was it to which drug) True penicillin allergy only occurs in 7 ndash 23 of those who give a history
Within this Guideline
Drugs in RED are contraindicated in penicillin allergy
Drugs in ORANGE should be prescribed with caution They may be appropriate for a mild allergy (eg rash delayed reaction) but should not be prescribed for patients with severe penicillin allergy (eg anaphylaxis angioedema) or cephalosporin allergy
Drugs in GREEN are considered safe in penicillin allergy Please note that a patient with penicillin allergy is three times more likely to react to ANY drug owing to the atopic nature of the condition
Therapeutic Drug Monitoring
Drugs such as vancomycin teicoplanin and the aminoglycosides (eg gentamicin amikacin) require careful monitoring of drug levels This is of particular importance when there is renal impairment (See Appendices 3 4 5 and 6 and Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Use of a once ndash daily dose of gentamicin is now adopted in the Trust for serious Gram negative sepsis When this method of gentamicin administration is considered the Trust Policy for Gentamicin Dosing and Monitoring for Adults should be adhered to
NB When in doubt about any aspect of the use of antibiotics always ask a Consultant
Microbiologist for advice
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 7 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 USEFUL TELEPHONE NUMBERS Microbiology Laboratory This department has now moved to Cambridge University Hospitals NHS Trust and is based at Addenbrookersquos Hospital For urgent results call 01223 257037
For queries around samples contact The Pathology Partnership (TPP) via email between 0800
and 2000 at thepartnershelpdesknhsnet or call 0333 1032220
NB Always telephone the laboratory at Lister on ext 4694 when sending urgent
specimens that require immediate processing Consultants Between 9am ndash 5pm Monday ndash Friday
The Consultant Microbiologist taking telephone enquiries during the day may be contacted via the daytime Microbiology mobile (07500 975834)
Out of hours (including weekends Bank Holidays)
Contact the Consultant Medical Microbiologist on call via hospital switchboard This is also the route for contacting the on-call Biomedical Scientist
Antimicrobial Pharmacist bleep 5933 Other Numbers
Public Health England 0300 303 8537 (Notification of infectious diseases)
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 8 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
3 RESTRICTED ANTIBIOTICS
A number of antibiotics are restricted and should ONLY be used for the indications outlined in the following chapters OR with input from a Consultant Microbiologist The list includes the following agents Quinolones (ciprofloxacin and levofloxacin)
Glycopeptides (vancomycin and teicoplanin)
Aminoglycosides (gentamicin amikacin streptomycin)
Cephalosporins (eg cefuroxime)
Carbapenems (imipenem meropenem and ertapenem)
Colistin (nebulisedintravenous)
Piperacillintazobactam
Temocillin
Fosfomycin (except Urology)
Rifampicin (except by Respiratory Team for TB)
Azithromycin
Tigecycline
Daptomycin
Linezolid If any of the above are prescribed for an indication outside this Guideline the Ward Pharmacist will contact the prescriber and a Consultant Microbiologist to ensure they are authorised for use Where these antibiotics are held as stock in defined areas (eg Theatres ITU Renal) they must not be supplied to other wards or clinical areas without the authorisation of a Consultant Microbiologist Out of hours the Duty Matron will not supply a restricted antimicrobial agent from the emergency drug cupboard or authorise its ldquoloanrdquo from a defined area other than for a use outlined in this Guideline without the approval of a Consultant Microbiologist The Emergency Duty Pharmacist will not attend to supply a restricted antimicrobial agent without the authorisation of a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 9 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections
Infection Category Antimicrobials Comments
Cellulitis
Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus
Duration 7 ndash 10 days
Discuss with Consultant Microbiologist if no response after 72 hours
There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)
Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist
Mild (penicillin allergy)
Clarithromycin 500mg bd PO
Mild (MRSA colonised)
Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive
Severe Flucloxacillin 1 ndash 2g qds IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Cellulitis due to IV cannula
Remove cannula and manage as for lsquoCellulitisrsquo
Leg Ulcers pressure sores (non-diabetic)
No clinical evidence of
infection No antibiotics required
Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo
Surgical wound infection (Clean surgery)
Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus
Surgical wound infection (contaminated
abdomino-pelvic surgery)
Mild Manage as for lsquoCellulitisrsquo
Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection
Severe Co-amoxiclav 12g TDS IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 3 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Contents
Section Page
1 Introduction and General Principles 4
2 Useful Telephone Numbers 7
3 Restricted Antibiotics 8
4 Conditions and Recommended Treatment 9
Skin and Soft Tissue Infections 9
Urinary Tract Infections 13
Respiratory Tract Infections 14
GastrointestinalIntra-abdominal Infections 30
Central Nervous System Infections 34
Bone and Joint Infections 35
Endocarditis 36
Septicaemia (including Neutropenic Sepsis) 37
ENT (Oropharyngeal) Infections 39
Ophthalmic Infections 40
Genitourinary Tract InfectionsSexually Transmitted Diseases 41
5 Antibiotic Prophylaxis for Surgery 43
GastrointestinalIntra-abdominal 44
Genitourinary 45
Obstetric amp Gynaecological 46
Plastic and Reconstructive 46
Orthopaedic 47
Vascular Surgery 48
Thoracic Surgery amp Head amp Neck Surgery 48
6 Other Antibiotic Prophylaxis 49
7 Further reading 50
Appendix 1 Guideline for Switch Antibiotic Therapy 51
Appendix 2 Penicillin Allergy and Poster General Points on Allergies 53
Appendix 3 Protocol for Vancomycin Administration in Adults 55
Appendix 4 Teicoplanin dose banding in adults with good renal function 56
Appendix 5 Extended Interval Gentamicin Dosing 59
Appendix 6 Extended Interval Amikacin Dosing 60
Appendix 6a Calculation of Corrected Body Weight (CBW) for Dosing in Obese Patients
63
8 Further reading 64
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 4 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
1 INTRODUCTION
This document is the Trustrsquos Guideline for the use of antibiotics If deviation from this Guideline
is clinically indicated a Consultant Microbiologist must be informed to assess the need and to authorise any deviation agreed to be necessary
This Guideline is for antibiotic use in non-pregnant adults (ie aged 16 years and over) with normal renal and liver function unless specifically stated All doses given therefore assume normal renal function If renal function is impaired please discuss appropriate dosing with the Pharmacist
For pregnant women children and neonates please refer to the appropriate Guidelines on the Knowledge Centre
Sections of this Guideline may be revised in times of outbreaks or drug shortages
General Principles of Antimicrobial Prescribing
Avoid unnecessary antibiotic use
Antibiotics have harmful effects eg allergy toxicity superinfection (eg Clostridium difficile colitis) and the generation of microbial resistance in the individual and the community at large
Appropriate microbiological samples must be taken before starting antibiotic therapy
A microbiological diagnosis is vital for optimal treatment of severe infections such as meningitis osteomyelitis endocarditis and septicaemia
Effective therapy should be commenced promptly in patients with life-threatening infection
When there is a critical need eg clinical diagnosis of meningococcal disease antibiotic therapy should be started without delay Prescribing should be in accordance with this Guideline which takes account of local resistance patterns Deviations from this Guideline should be discussed with the Consultant Microbiologist
Consider patient-specific factors when prescribing antibiotics
Choice of initial (or empirical) antibiotics will depend on whether the infection is hospital or community acquired severity site of infection colonisation with multi-resistant organisms recent antibiotic history immune-competence pregnancy allergies and drug interactions
All antibiotics should be clearly prescribed giving dosage frequency and duration
The dedicated antimicrobial section of the drug chart should be used for all antibiotic prescriptions with the exception of gentamicin and amikacin The diagnosisreason for antimicrobial therapy and anticipated duration of therapy should be clearly documented in the patientrsquos medical notes AND on the drug chart
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 5 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Use oral antibiotics whenever possible in preference to intravenous antibiotics
Intravenous therapy can be given at a much higher dose achieve higher drug concentration in blood and tissue and is more reliably absorbed than oral antibiotics However it has important disadvantages such as the risk of super infections (eg cannula-related wound infection and septicaemia) and greater expense Therefore the intravenous route should be reserved for patients with severe infections threatening life or major disability (eg endocarditis meningitis and septicaemia) patients who cannot tolerate or absorb oral medication or when no oral antibiotic alternative is available
Surgical prophylaxis should be administered as a single IV dose
Where antibiotics have been shown to be effective for surgical prophylaxis they should be given as a single dose 30 minutes prior to incision With the exceptions given in this Guideline (ie prolonged surgery gt5hr significant blood loss gt15L prosthetic implant surgery) further prophylactic doses are not indicated (See pages 41 ndash 46)
Antimicrobial Review and Stewardship
All antibiotics should be reviewed daily and the review documented in the patientrsquos medical notes
In particular the patient should be reviewed at 48 hrs and again at 5 days in
conjunction with culture results and then a clinical decision made and documented re whether to
Stop antibiotics (no evidence of infection)
Switch from intravenous to oral therapy (refer to the Guideline for Switch Antibiotic Therapy ndash see Appendix 1)
Change antibiotics (de-escalate switch or substitute based on culture results amp other investigations)
Continue (review again after a further 24 hours)
Refer to OPAT (Outpatient Parenteral Antibiotic Therapy)
The total duration of antibiotics should not normally exceed 5 to 7 days for acute infections
Cautions to Antimicrobial Prescribing
Clostridium difficile
The following antibiotic classes are strongly associated with C difficile infection and pseudomembranous colitis Cephalosporins Ciprofloxacin and Clindamycin Use of these antibiotics is strictly restricted They should ONLY be used for the specific indications in this Guideline OR upon the advice of the Consultant Microbiologist
With the exceptions given in this Guideline surgical prophylaxis should be single dose and should NOT continue after surgery Antibiotics continued after surgery have been shown to increase C difficile infection 3 times without any further reduction in infection
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 6 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Multi-resistant organisms
Use of antibiotics in patients colonised or infected with meticillin resistant Staphylococcus aureus (MRSA) vancomycin resistant enterococci (VRE) or multi-resistant coliforms requires careful consideration of the predicted benefit of antibiotics against the potential disadvantages and also of the choice of antibiotic agent
Advice of a Consultant Microbiologist should always be sought prior to the initiation of such antibiotic courses
Prescribing in penicillin allergic patients
General guidance on appropriate antibiotics to use in the penicillin allergic patient is included at the end of this document (See Appendix 2)
A careful and thorough allergy history is important to differentiate true penicillin allergy from drug intolerance and other reactions (ie what was the reaction when was it to which drug) True penicillin allergy only occurs in 7 ndash 23 of those who give a history
Within this Guideline
Drugs in RED are contraindicated in penicillin allergy
Drugs in ORANGE should be prescribed with caution They may be appropriate for a mild allergy (eg rash delayed reaction) but should not be prescribed for patients with severe penicillin allergy (eg anaphylaxis angioedema) or cephalosporin allergy
Drugs in GREEN are considered safe in penicillin allergy Please note that a patient with penicillin allergy is three times more likely to react to ANY drug owing to the atopic nature of the condition
Therapeutic Drug Monitoring
Drugs such as vancomycin teicoplanin and the aminoglycosides (eg gentamicin amikacin) require careful monitoring of drug levels This is of particular importance when there is renal impairment (See Appendices 3 4 5 and 6 and Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Use of a once ndash daily dose of gentamicin is now adopted in the Trust for serious Gram negative sepsis When this method of gentamicin administration is considered the Trust Policy for Gentamicin Dosing and Monitoring for Adults should be adhered to
NB When in doubt about any aspect of the use of antibiotics always ask a Consultant
Microbiologist for advice
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 7 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 USEFUL TELEPHONE NUMBERS Microbiology Laboratory This department has now moved to Cambridge University Hospitals NHS Trust and is based at Addenbrookersquos Hospital For urgent results call 01223 257037
For queries around samples contact The Pathology Partnership (TPP) via email between 0800
and 2000 at thepartnershelpdesknhsnet or call 0333 1032220
NB Always telephone the laboratory at Lister on ext 4694 when sending urgent
specimens that require immediate processing Consultants Between 9am ndash 5pm Monday ndash Friday
The Consultant Microbiologist taking telephone enquiries during the day may be contacted via the daytime Microbiology mobile (07500 975834)
Out of hours (including weekends Bank Holidays)
Contact the Consultant Medical Microbiologist on call via hospital switchboard This is also the route for contacting the on-call Biomedical Scientist
Antimicrobial Pharmacist bleep 5933 Other Numbers
Public Health England 0300 303 8537 (Notification of infectious diseases)
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 8 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
3 RESTRICTED ANTIBIOTICS
A number of antibiotics are restricted and should ONLY be used for the indications outlined in the following chapters OR with input from a Consultant Microbiologist The list includes the following agents Quinolones (ciprofloxacin and levofloxacin)
Glycopeptides (vancomycin and teicoplanin)
Aminoglycosides (gentamicin amikacin streptomycin)
Cephalosporins (eg cefuroxime)
Carbapenems (imipenem meropenem and ertapenem)
Colistin (nebulisedintravenous)
Piperacillintazobactam
Temocillin
Fosfomycin (except Urology)
Rifampicin (except by Respiratory Team for TB)
Azithromycin
Tigecycline
Daptomycin
Linezolid If any of the above are prescribed for an indication outside this Guideline the Ward Pharmacist will contact the prescriber and a Consultant Microbiologist to ensure they are authorised for use Where these antibiotics are held as stock in defined areas (eg Theatres ITU Renal) they must not be supplied to other wards or clinical areas without the authorisation of a Consultant Microbiologist Out of hours the Duty Matron will not supply a restricted antimicrobial agent from the emergency drug cupboard or authorise its ldquoloanrdquo from a defined area other than for a use outlined in this Guideline without the approval of a Consultant Microbiologist The Emergency Duty Pharmacist will not attend to supply a restricted antimicrobial agent without the authorisation of a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 9 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections
Infection Category Antimicrobials Comments
Cellulitis
Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus
Duration 7 ndash 10 days
Discuss with Consultant Microbiologist if no response after 72 hours
There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)
Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist
Mild (penicillin allergy)
Clarithromycin 500mg bd PO
Mild (MRSA colonised)
Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive
Severe Flucloxacillin 1 ndash 2g qds IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Cellulitis due to IV cannula
Remove cannula and manage as for lsquoCellulitisrsquo
Leg Ulcers pressure sores (non-diabetic)
No clinical evidence of
infection No antibiotics required
Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo
Surgical wound infection (Clean surgery)
Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus
Surgical wound infection (contaminated
abdomino-pelvic surgery)
Mild Manage as for lsquoCellulitisrsquo
Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection
Severe Co-amoxiclav 12g TDS IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 4 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
1 INTRODUCTION
This document is the Trustrsquos Guideline for the use of antibiotics If deviation from this Guideline
is clinically indicated a Consultant Microbiologist must be informed to assess the need and to authorise any deviation agreed to be necessary
This Guideline is for antibiotic use in non-pregnant adults (ie aged 16 years and over) with normal renal and liver function unless specifically stated All doses given therefore assume normal renal function If renal function is impaired please discuss appropriate dosing with the Pharmacist
For pregnant women children and neonates please refer to the appropriate Guidelines on the Knowledge Centre
Sections of this Guideline may be revised in times of outbreaks or drug shortages
General Principles of Antimicrobial Prescribing
Avoid unnecessary antibiotic use
Antibiotics have harmful effects eg allergy toxicity superinfection (eg Clostridium difficile colitis) and the generation of microbial resistance in the individual and the community at large
Appropriate microbiological samples must be taken before starting antibiotic therapy
A microbiological diagnosis is vital for optimal treatment of severe infections such as meningitis osteomyelitis endocarditis and septicaemia
Effective therapy should be commenced promptly in patients with life-threatening infection
When there is a critical need eg clinical diagnosis of meningococcal disease antibiotic therapy should be started without delay Prescribing should be in accordance with this Guideline which takes account of local resistance patterns Deviations from this Guideline should be discussed with the Consultant Microbiologist
Consider patient-specific factors when prescribing antibiotics
Choice of initial (or empirical) antibiotics will depend on whether the infection is hospital or community acquired severity site of infection colonisation with multi-resistant organisms recent antibiotic history immune-competence pregnancy allergies and drug interactions
All antibiotics should be clearly prescribed giving dosage frequency and duration
The dedicated antimicrobial section of the drug chart should be used for all antibiotic prescriptions with the exception of gentamicin and amikacin The diagnosisreason for antimicrobial therapy and anticipated duration of therapy should be clearly documented in the patientrsquos medical notes AND on the drug chart
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 5 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Use oral antibiotics whenever possible in preference to intravenous antibiotics
Intravenous therapy can be given at a much higher dose achieve higher drug concentration in blood and tissue and is more reliably absorbed than oral antibiotics However it has important disadvantages such as the risk of super infections (eg cannula-related wound infection and septicaemia) and greater expense Therefore the intravenous route should be reserved for patients with severe infections threatening life or major disability (eg endocarditis meningitis and septicaemia) patients who cannot tolerate or absorb oral medication or when no oral antibiotic alternative is available
Surgical prophylaxis should be administered as a single IV dose
Where antibiotics have been shown to be effective for surgical prophylaxis they should be given as a single dose 30 minutes prior to incision With the exceptions given in this Guideline (ie prolonged surgery gt5hr significant blood loss gt15L prosthetic implant surgery) further prophylactic doses are not indicated (See pages 41 ndash 46)
Antimicrobial Review and Stewardship
All antibiotics should be reviewed daily and the review documented in the patientrsquos medical notes
In particular the patient should be reviewed at 48 hrs and again at 5 days in
conjunction with culture results and then a clinical decision made and documented re whether to
Stop antibiotics (no evidence of infection)
Switch from intravenous to oral therapy (refer to the Guideline for Switch Antibiotic Therapy ndash see Appendix 1)
Change antibiotics (de-escalate switch or substitute based on culture results amp other investigations)
Continue (review again after a further 24 hours)
Refer to OPAT (Outpatient Parenteral Antibiotic Therapy)
The total duration of antibiotics should not normally exceed 5 to 7 days for acute infections
Cautions to Antimicrobial Prescribing
Clostridium difficile
The following antibiotic classes are strongly associated with C difficile infection and pseudomembranous colitis Cephalosporins Ciprofloxacin and Clindamycin Use of these antibiotics is strictly restricted They should ONLY be used for the specific indications in this Guideline OR upon the advice of the Consultant Microbiologist
With the exceptions given in this Guideline surgical prophylaxis should be single dose and should NOT continue after surgery Antibiotics continued after surgery have been shown to increase C difficile infection 3 times without any further reduction in infection
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 6 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Multi-resistant organisms
Use of antibiotics in patients colonised or infected with meticillin resistant Staphylococcus aureus (MRSA) vancomycin resistant enterococci (VRE) or multi-resistant coliforms requires careful consideration of the predicted benefit of antibiotics against the potential disadvantages and also of the choice of antibiotic agent
Advice of a Consultant Microbiologist should always be sought prior to the initiation of such antibiotic courses
Prescribing in penicillin allergic patients
General guidance on appropriate antibiotics to use in the penicillin allergic patient is included at the end of this document (See Appendix 2)
A careful and thorough allergy history is important to differentiate true penicillin allergy from drug intolerance and other reactions (ie what was the reaction when was it to which drug) True penicillin allergy only occurs in 7 ndash 23 of those who give a history
Within this Guideline
Drugs in RED are contraindicated in penicillin allergy
Drugs in ORANGE should be prescribed with caution They may be appropriate for a mild allergy (eg rash delayed reaction) but should not be prescribed for patients with severe penicillin allergy (eg anaphylaxis angioedema) or cephalosporin allergy
Drugs in GREEN are considered safe in penicillin allergy Please note that a patient with penicillin allergy is three times more likely to react to ANY drug owing to the atopic nature of the condition
Therapeutic Drug Monitoring
Drugs such as vancomycin teicoplanin and the aminoglycosides (eg gentamicin amikacin) require careful monitoring of drug levels This is of particular importance when there is renal impairment (See Appendices 3 4 5 and 6 and Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Use of a once ndash daily dose of gentamicin is now adopted in the Trust for serious Gram negative sepsis When this method of gentamicin administration is considered the Trust Policy for Gentamicin Dosing and Monitoring for Adults should be adhered to
NB When in doubt about any aspect of the use of antibiotics always ask a Consultant
Microbiologist for advice
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 7 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 USEFUL TELEPHONE NUMBERS Microbiology Laboratory This department has now moved to Cambridge University Hospitals NHS Trust and is based at Addenbrookersquos Hospital For urgent results call 01223 257037
For queries around samples contact The Pathology Partnership (TPP) via email between 0800
and 2000 at thepartnershelpdesknhsnet or call 0333 1032220
NB Always telephone the laboratory at Lister on ext 4694 when sending urgent
specimens that require immediate processing Consultants Between 9am ndash 5pm Monday ndash Friday
The Consultant Microbiologist taking telephone enquiries during the day may be contacted via the daytime Microbiology mobile (07500 975834)
Out of hours (including weekends Bank Holidays)
Contact the Consultant Medical Microbiologist on call via hospital switchboard This is also the route for contacting the on-call Biomedical Scientist
Antimicrobial Pharmacist bleep 5933 Other Numbers
Public Health England 0300 303 8537 (Notification of infectious diseases)
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 8 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
3 RESTRICTED ANTIBIOTICS
A number of antibiotics are restricted and should ONLY be used for the indications outlined in the following chapters OR with input from a Consultant Microbiologist The list includes the following agents Quinolones (ciprofloxacin and levofloxacin)
Glycopeptides (vancomycin and teicoplanin)
Aminoglycosides (gentamicin amikacin streptomycin)
Cephalosporins (eg cefuroxime)
Carbapenems (imipenem meropenem and ertapenem)
Colistin (nebulisedintravenous)
Piperacillintazobactam
Temocillin
Fosfomycin (except Urology)
Rifampicin (except by Respiratory Team for TB)
Azithromycin
Tigecycline
Daptomycin
Linezolid If any of the above are prescribed for an indication outside this Guideline the Ward Pharmacist will contact the prescriber and a Consultant Microbiologist to ensure they are authorised for use Where these antibiotics are held as stock in defined areas (eg Theatres ITU Renal) they must not be supplied to other wards or clinical areas without the authorisation of a Consultant Microbiologist Out of hours the Duty Matron will not supply a restricted antimicrobial agent from the emergency drug cupboard or authorise its ldquoloanrdquo from a defined area other than for a use outlined in this Guideline without the approval of a Consultant Microbiologist The Emergency Duty Pharmacist will not attend to supply a restricted antimicrobial agent without the authorisation of a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 9 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections
Infection Category Antimicrobials Comments
Cellulitis
Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus
Duration 7 ndash 10 days
Discuss with Consultant Microbiologist if no response after 72 hours
There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)
Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist
Mild (penicillin allergy)
Clarithromycin 500mg bd PO
Mild (MRSA colonised)
Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive
Severe Flucloxacillin 1 ndash 2g qds IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Cellulitis due to IV cannula
Remove cannula and manage as for lsquoCellulitisrsquo
Leg Ulcers pressure sores (non-diabetic)
No clinical evidence of
infection No antibiotics required
Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo
Surgical wound infection (Clean surgery)
Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus
Surgical wound infection (contaminated
abdomino-pelvic surgery)
Mild Manage as for lsquoCellulitisrsquo
Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection
Severe Co-amoxiclav 12g TDS IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 5 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Use oral antibiotics whenever possible in preference to intravenous antibiotics
Intravenous therapy can be given at a much higher dose achieve higher drug concentration in blood and tissue and is more reliably absorbed than oral antibiotics However it has important disadvantages such as the risk of super infections (eg cannula-related wound infection and septicaemia) and greater expense Therefore the intravenous route should be reserved for patients with severe infections threatening life or major disability (eg endocarditis meningitis and septicaemia) patients who cannot tolerate or absorb oral medication or when no oral antibiotic alternative is available
Surgical prophylaxis should be administered as a single IV dose
Where antibiotics have been shown to be effective for surgical prophylaxis they should be given as a single dose 30 minutes prior to incision With the exceptions given in this Guideline (ie prolonged surgery gt5hr significant blood loss gt15L prosthetic implant surgery) further prophylactic doses are not indicated (See pages 41 ndash 46)
Antimicrobial Review and Stewardship
All antibiotics should be reviewed daily and the review documented in the patientrsquos medical notes
In particular the patient should be reviewed at 48 hrs and again at 5 days in
conjunction with culture results and then a clinical decision made and documented re whether to
Stop antibiotics (no evidence of infection)
Switch from intravenous to oral therapy (refer to the Guideline for Switch Antibiotic Therapy ndash see Appendix 1)
Change antibiotics (de-escalate switch or substitute based on culture results amp other investigations)
Continue (review again after a further 24 hours)
Refer to OPAT (Outpatient Parenteral Antibiotic Therapy)
The total duration of antibiotics should not normally exceed 5 to 7 days for acute infections
Cautions to Antimicrobial Prescribing
Clostridium difficile
The following antibiotic classes are strongly associated with C difficile infection and pseudomembranous colitis Cephalosporins Ciprofloxacin and Clindamycin Use of these antibiotics is strictly restricted They should ONLY be used for the specific indications in this Guideline OR upon the advice of the Consultant Microbiologist
With the exceptions given in this Guideline surgical prophylaxis should be single dose and should NOT continue after surgery Antibiotics continued after surgery have been shown to increase C difficile infection 3 times without any further reduction in infection
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 6 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Multi-resistant organisms
Use of antibiotics in patients colonised or infected with meticillin resistant Staphylococcus aureus (MRSA) vancomycin resistant enterococci (VRE) or multi-resistant coliforms requires careful consideration of the predicted benefit of antibiotics against the potential disadvantages and also of the choice of antibiotic agent
Advice of a Consultant Microbiologist should always be sought prior to the initiation of such antibiotic courses
Prescribing in penicillin allergic patients
General guidance on appropriate antibiotics to use in the penicillin allergic patient is included at the end of this document (See Appendix 2)
A careful and thorough allergy history is important to differentiate true penicillin allergy from drug intolerance and other reactions (ie what was the reaction when was it to which drug) True penicillin allergy only occurs in 7 ndash 23 of those who give a history
Within this Guideline
Drugs in RED are contraindicated in penicillin allergy
Drugs in ORANGE should be prescribed with caution They may be appropriate for a mild allergy (eg rash delayed reaction) but should not be prescribed for patients with severe penicillin allergy (eg anaphylaxis angioedema) or cephalosporin allergy
Drugs in GREEN are considered safe in penicillin allergy Please note that a patient with penicillin allergy is three times more likely to react to ANY drug owing to the atopic nature of the condition
Therapeutic Drug Monitoring
Drugs such as vancomycin teicoplanin and the aminoglycosides (eg gentamicin amikacin) require careful monitoring of drug levels This is of particular importance when there is renal impairment (See Appendices 3 4 5 and 6 and Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Use of a once ndash daily dose of gentamicin is now adopted in the Trust for serious Gram negative sepsis When this method of gentamicin administration is considered the Trust Policy for Gentamicin Dosing and Monitoring for Adults should be adhered to
NB When in doubt about any aspect of the use of antibiotics always ask a Consultant
Microbiologist for advice
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 7 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 USEFUL TELEPHONE NUMBERS Microbiology Laboratory This department has now moved to Cambridge University Hospitals NHS Trust and is based at Addenbrookersquos Hospital For urgent results call 01223 257037
For queries around samples contact The Pathology Partnership (TPP) via email between 0800
and 2000 at thepartnershelpdesknhsnet or call 0333 1032220
NB Always telephone the laboratory at Lister on ext 4694 when sending urgent
specimens that require immediate processing Consultants Between 9am ndash 5pm Monday ndash Friday
The Consultant Microbiologist taking telephone enquiries during the day may be contacted via the daytime Microbiology mobile (07500 975834)
Out of hours (including weekends Bank Holidays)
Contact the Consultant Medical Microbiologist on call via hospital switchboard This is also the route for contacting the on-call Biomedical Scientist
Antimicrobial Pharmacist bleep 5933 Other Numbers
Public Health England 0300 303 8537 (Notification of infectious diseases)
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 8 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
3 RESTRICTED ANTIBIOTICS
A number of antibiotics are restricted and should ONLY be used for the indications outlined in the following chapters OR with input from a Consultant Microbiologist The list includes the following agents Quinolones (ciprofloxacin and levofloxacin)
Glycopeptides (vancomycin and teicoplanin)
Aminoglycosides (gentamicin amikacin streptomycin)
Cephalosporins (eg cefuroxime)
Carbapenems (imipenem meropenem and ertapenem)
Colistin (nebulisedintravenous)
Piperacillintazobactam
Temocillin
Fosfomycin (except Urology)
Rifampicin (except by Respiratory Team for TB)
Azithromycin
Tigecycline
Daptomycin
Linezolid If any of the above are prescribed for an indication outside this Guideline the Ward Pharmacist will contact the prescriber and a Consultant Microbiologist to ensure they are authorised for use Where these antibiotics are held as stock in defined areas (eg Theatres ITU Renal) they must not be supplied to other wards or clinical areas without the authorisation of a Consultant Microbiologist Out of hours the Duty Matron will not supply a restricted antimicrobial agent from the emergency drug cupboard or authorise its ldquoloanrdquo from a defined area other than for a use outlined in this Guideline without the approval of a Consultant Microbiologist The Emergency Duty Pharmacist will not attend to supply a restricted antimicrobial agent without the authorisation of a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 9 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections
Infection Category Antimicrobials Comments
Cellulitis
Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus
Duration 7 ndash 10 days
Discuss with Consultant Microbiologist if no response after 72 hours
There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)
Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist
Mild (penicillin allergy)
Clarithromycin 500mg bd PO
Mild (MRSA colonised)
Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive
Severe Flucloxacillin 1 ndash 2g qds IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Cellulitis due to IV cannula
Remove cannula and manage as for lsquoCellulitisrsquo
Leg Ulcers pressure sores (non-diabetic)
No clinical evidence of
infection No antibiotics required
Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo
Surgical wound infection (Clean surgery)
Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus
Surgical wound infection (contaminated
abdomino-pelvic surgery)
Mild Manage as for lsquoCellulitisrsquo
Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection
Severe Co-amoxiclav 12g TDS IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 6 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Multi-resistant organisms
Use of antibiotics in patients colonised or infected with meticillin resistant Staphylococcus aureus (MRSA) vancomycin resistant enterococci (VRE) or multi-resistant coliforms requires careful consideration of the predicted benefit of antibiotics against the potential disadvantages and also of the choice of antibiotic agent
Advice of a Consultant Microbiologist should always be sought prior to the initiation of such antibiotic courses
Prescribing in penicillin allergic patients
General guidance on appropriate antibiotics to use in the penicillin allergic patient is included at the end of this document (See Appendix 2)
A careful and thorough allergy history is important to differentiate true penicillin allergy from drug intolerance and other reactions (ie what was the reaction when was it to which drug) True penicillin allergy only occurs in 7 ndash 23 of those who give a history
Within this Guideline
Drugs in RED are contraindicated in penicillin allergy
Drugs in ORANGE should be prescribed with caution They may be appropriate for a mild allergy (eg rash delayed reaction) but should not be prescribed for patients with severe penicillin allergy (eg anaphylaxis angioedema) or cephalosporin allergy
Drugs in GREEN are considered safe in penicillin allergy Please note that a patient with penicillin allergy is three times more likely to react to ANY drug owing to the atopic nature of the condition
Therapeutic Drug Monitoring
Drugs such as vancomycin teicoplanin and the aminoglycosides (eg gentamicin amikacin) require careful monitoring of drug levels This is of particular importance when there is renal impairment (See Appendices 3 4 5 and 6 and Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Use of a once ndash daily dose of gentamicin is now adopted in the Trust for serious Gram negative sepsis When this method of gentamicin administration is considered the Trust Policy for Gentamicin Dosing and Monitoring for Adults should be adhered to
NB When in doubt about any aspect of the use of antibiotics always ask a Consultant
Microbiologist for advice
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 7 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 USEFUL TELEPHONE NUMBERS Microbiology Laboratory This department has now moved to Cambridge University Hospitals NHS Trust and is based at Addenbrookersquos Hospital For urgent results call 01223 257037
For queries around samples contact The Pathology Partnership (TPP) via email between 0800
and 2000 at thepartnershelpdesknhsnet or call 0333 1032220
NB Always telephone the laboratory at Lister on ext 4694 when sending urgent
specimens that require immediate processing Consultants Between 9am ndash 5pm Monday ndash Friday
The Consultant Microbiologist taking telephone enquiries during the day may be contacted via the daytime Microbiology mobile (07500 975834)
Out of hours (including weekends Bank Holidays)
Contact the Consultant Medical Microbiologist on call via hospital switchboard This is also the route for contacting the on-call Biomedical Scientist
Antimicrobial Pharmacist bleep 5933 Other Numbers
Public Health England 0300 303 8537 (Notification of infectious diseases)
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 8 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
3 RESTRICTED ANTIBIOTICS
A number of antibiotics are restricted and should ONLY be used for the indications outlined in the following chapters OR with input from a Consultant Microbiologist The list includes the following agents Quinolones (ciprofloxacin and levofloxacin)
Glycopeptides (vancomycin and teicoplanin)
Aminoglycosides (gentamicin amikacin streptomycin)
Cephalosporins (eg cefuroxime)
Carbapenems (imipenem meropenem and ertapenem)
Colistin (nebulisedintravenous)
Piperacillintazobactam
Temocillin
Fosfomycin (except Urology)
Rifampicin (except by Respiratory Team for TB)
Azithromycin
Tigecycline
Daptomycin
Linezolid If any of the above are prescribed for an indication outside this Guideline the Ward Pharmacist will contact the prescriber and a Consultant Microbiologist to ensure they are authorised for use Where these antibiotics are held as stock in defined areas (eg Theatres ITU Renal) they must not be supplied to other wards or clinical areas without the authorisation of a Consultant Microbiologist Out of hours the Duty Matron will not supply a restricted antimicrobial agent from the emergency drug cupboard or authorise its ldquoloanrdquo from a defined area other than for a use outlined in this Guideline without the approval of a Consultant Microbiologist The Emergency Duty Pharmacist will not attend to supply a restricted antimicrobial agent without the authorisation of a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 9 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections
Infection Category Antimicrobials Comments
Cellulitis
Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus
Duration 7 ndash 10 days
Discuss with Consultant Microbiologist if no response after 72 hours
There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)
Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist
Mild (penicillin allergy)
Clarithromycin 500mg bd PO
Mild (MRSA colonised)
Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive
Severe Flucloxacillin 1 ndash 2g qds IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Cellulitis due to IV cannula
Remove cannula and manage as for lsquoCellulitisrsquo
Leg Ulcers pressure sores (non-diabetic)
No clinical evidence of
infection No antibiotics required
Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo
Surgical wound infection (Clean surgery)
Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus
Surgical wound infection (contaminated
abdomino-pelvic surgery)
Mild Manage as for lsquoCellulitisrsquo
Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection
Severe Co-amoxiclav 12g TDS IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 7 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 USEFUL TELEPHONE NUMBERS Microbiology Laboratory This department has now moved to Cambridge University Hospitals NHS Trust and is based at Addenbrookersquos Hospital For urgent results call 01223 257037
For queries around samples contact The Pathology Partnership (TPP) via email between 0800
and 2000 at thepartnershelpdesknhsnet or call 0333 1032220
NB Always telephone the laboratory at Lister on ext 4694 when sending urgent
specimens that require immediate processing Consultants Between 9am ndash 5pm Monday ndash Friday
The Consultant Microbiologist taking telephone enquiries during the day may be contacted via the daytime Microbiology mobile (07500 975834)
Out of hours (including weekends Bank Holidays)
Contact the Consultant Medical Microbiologist on call via hospital switchboard This is also the route for contacting the on-call Biomedical Scientist
Antimicrobial Pharmacist bleep 5933 Other Numbers
Public Health England 0300 303 8537 (Notification of infectious diseases)
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 8 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
3 RESTRICTED ANTIBIOTICS
A number of antibiotics are restricted and should ONLY be used for the indications outlined in the following chapters OR with input from a Consultant Microbiologist The list includes the following agents Quinolones (ciprofloxacin and levofloxacin)
Glycopeptides (vancomycin and teicoplanin)
Aminoglycosides (gentamicin amikacin streptomycin)
Cephalosporins (eg cefuroxime)
Carbapenems (imipenem meropenem and ertapenem)
Colistin (nebulisedintravenous)
Piperacillintazobactam
Temocillin
Fosfomycin (except Urology)
Rifampicin (except by Respiratory Team for TB)
Azithromycin
Tigecycline
Daptomycin
Linezolid If any of the above are prescribed for an indication outside this Guideline the Ward Pharmacist will contact the prescriber and a Consultant Microbiologist to ensure they are authorised for use Where these antibiotics are held as stock in defined areas (eg Theatres ITU Renal) they must not be supplied to other wards or clinical areas without the authorisation of a Consultant Microbiologist Out of hours the Duty Matron will not supply a restricted antimicrobial agent from the emergency drug cupboard or authorise its ldquoloanrdquo from a defined area other than for a use outlined in this Guideline without the approval of a Consultant Microbiologist The Emergency Duty Pharmacist will not attend to supply a restricted antimicrobial agent without the authorisation of a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 9 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections
Infection Category Antimicrobials Comments
Cellulitis
Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus
Duration 7 ndash 10 days
Discuss with Consultant Microbiologist if no response after 72 hours
There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)
Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist
Mild (penicillin allergy)
Clarithromycin 500mg bd PO
Mild (MRSA colonised)
Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive
Severe Flucloxacillin 1 ndash 2g qds IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Cellulitis due to IV cannula
Remove cannula and manage as for lsquoCellulitisrsquo
Leg Ulcers pressure sores (non-diabetic)
No clinical evidence of
infection No antibiotics required
Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo
Surgical wound infection (Clean surgery)
Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus
Surgical wound infection (contaminated
abdomino-pelvic surgery)
Mild Manage as for lsquoCellulitisrsquo
Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection
Severe Co-amoxiclav 12g TDS IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 8 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
3 RESTRICTED ANTIBIOTICS
A number of antibiotics are restricted and should ONLY be used for the indications outlined in the following chapters OR with input from a Consultant Microbiologist The list includes the following agents Quinolones (ciprofloxacin and levofloxacin)
Glycopeptides (vancomycin and teicoplanin)
Aminoglycosides (gentamicin amikacin streptomycin)
Cephalosporins (eg cefuroxime)
Carbapenems (imipenem meropenem and ertapenem)
Colistin (nebulisedintravenous)
Piperacillintazobactam
Temocillin
Fosfomycin (except Urology)
Rifampicin (except by Respiratory Team for TB)
Azithromycin
Tigecycline
Daptomycin
Linezolid If any of the above are prescribed for an indication outside this Guideline the Ward Pharmacist will contact the prescriber and a Consultant Microbiologist to ensure they are authorised for use Where these antibiotics are held as stock in defined areas (eg Theatres ITU Renal) they must not be supplied to other wards or clinical areas without the authorisation of a Consultant Microbiologist Out of hours the Duty Matron will not supply a restricted antimicrobial agent from the emergency drug cupboard or authorise its ldquoloanrdquo from a defined area other than for a use outlined in this Guideline without the approval of a Consultant Microbiologist The Emergency Duty Pharmacist will not attend to supply a restricted antimicrobial agent without the authorisation of a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 9 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections
Infection Category Antimicrobials Comments
Cellulitis
Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus
Duration 7 ndash 10 days
Discuss with Consultant Microbiologist if no response after 72 hours
There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)
Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist
Mild (penicillin allergy)
Clarithromycin 500mg bd PO
Mild (MRSA colonised)
Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive
Severe Flucloxacillin 1 ndash 2g qds IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Cellulitis due to IV cannula
Remove cannula and manage as for lsquoCellulitisrsquo
Leg Ulcers pressure sores (non-diabetic)
No clinical evidence of
infection No antibiotics required
Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo
Surgical wound infection (Clean surgery)
Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus
Surgical wound infection (contaminated
abdomino-pelvic surgery)
Mild Manage as for lsquoCellulitisrsquo
Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection
Severe Co-amoxiclav 12g TDS IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 9 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections
Infection Category Antimicrobials Comments
Cellulitis
Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus
Duration 7 ndash 10 days
Discuss with Consultant Microbiologist if no response after 72 hours
There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)
Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist
Mild (penicillin allergy)
Clarithromycin 500mg bd PO
Mild (MRSA colonised)
Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive
Severe Flucloxacillin 1 ndash 2g qds IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Cellulitis due to IV cannula
Remove cannula and manage as for lsquoCellulitisrsquo
Leg Ulcers pressure sores (non-diabetic)
No clinical evidence of
infection No antibiotics required
Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo
Surgical wound infection (Clean surgery)
Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus
Surgical wound infection (contaminated
abdomino-pelvic surgery)
Mild Manage as for lsquoCellulitisrsquo
Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection
Severe Co-amoxiclav 12g TDS IV
Severe (penicillin allergy MRSA colonised)
Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 10 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising fasciitis
1st Line
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV
Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes
Duration 14 days
All cases should be discussed with the Consultant Microbiologist
An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection
Alternative during piperacillin-tazobactam supply shortage
Flucloxacillin 2g QDS IV +
Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+
Clindamycin 600mg QDS IV
If MRSA colonised add
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Contact Consultant Microbiologist
MRSA colonised
Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 11 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Diabetic foot infections
Refer to the current Trust Guidelines on
Management of Active Diabetic Foot Infections
CGSG No 092
Uninfected Colonised ulcer
No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation
Mild
Flucloxacillin 1g QDS PO
Penicillin allergy Doxycycline 100mg BD PO
MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist
Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes
Mild infection
- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise
Duration 7 ndash 10 days
Moderate
Co-amoxiclav 12g TDS IV
Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Moderate infection ndash systemically stable but one of more features present
- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint
Severe
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
+ Metronidazole 500mg TDS IV
Discuss ongoing therapy with Consultant Microbiologist
Severe Infection
- Infection in a patient with systemic toxicity or metabolic instability
(eg tachycardia hypotension confusion vomiting acidosis etc)
Collect wound swabs and blood cultures prior to commencing antibiotics
Suspected Osteomyelitis
See ldquoBone and Joint Infection
Discuss with Consultant Microbiologist
Perform appropriate imaging to confirm the diagnosis
Obtain bone biopsydeep tissue specimens for culture
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 12 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Skin amp Soft Tissue Infections contdhellip
Infection Category Antimicrobials Comments
Animal or Human Bites
Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella
Duration 7 days
Wound toilet and surgical debridement may be required
For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated
Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss
Mild (penicillin allergy)
Doxycycline 100mg bd PO + Metronidazole 400mg tds PO
Severe Co-amoxiclav 12g tds IV
Severe (penicillin allergy)
Discuss with the Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 13 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Urinary Tract Infections
Infection Category Antimicrobials Comments
Uncomplicated UTI (eg simple cystitis without fever or loin
pain)
1st Line
Nitrofurantoin 50mg QDS PO
(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)
Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)
Treatment should be modified according to the most recent culture amp sensitivity test
2nd
amp 3rd
line treatment is indicated if
- 1st line therapy contraindicated or non-tolerated
- Treatment failure - Microbiological cultures indicate resistance to 1
st line but
susceptibility to 2nd
or 3rd
line treatment
If none of the given regimens are suitable discuss with Consultant Microbiologist
Duration Non-pregnant women 3 days Men 7 days
2nd
Line Trimethoprim 200mg BD PO
Unable to swallowtolerate oral
therapy
Co-amoxiclav 12g TDS IV
If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin allergy Discuss with Microbiology Consultant
Pregnant
Nitrofurantoin 50mg PO QDS
If Nitrofurantoin contra-indicated
Cefalexin 500mg TDS PO
Avoid Nitrofurantoin
- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy
Duration 7 days
Indwelling urinary catheter
Asymptomatic patient with
colonised catheter Antibiotic treatment not indicated
Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora
Symptomatic patient
Change catheter
Discuss empirical therapy with Consultant Microbiologist
Acute Pyelonephritis
Urosepsis
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent
culture amp sensitivity test
Review antibiotics at 48hr with the culture results
Duration Women 7 days Men 14 days Penicillin allergic
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Pregnancy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 14 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections
A Community acquired pneumonia (CAP)
Definition
Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR
New focal chest signs on examination PLUS
New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)
The illness is the primary reason for hospital admission and is managed as pneumonia
The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens
Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin
Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group
Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)
Assessment of Severity
The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)
Score one point for each of the following
Confusion
Urea gt 7 mmolL
Respiratory rate gt 30 breathsmin
Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg
Age gt 65 years
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 15 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission
Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen
Chest X-ray
Urea and electrolytes
Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy
CRP
Full blood count
Viral nose and throat swab for respiratory viruses especially during the winter influenzae season
Liver function tests ndash derangement seen with atypical infections
Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced
Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression
Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy
Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 16 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Duration and Comments
Community-acquired Pneumonia
Mild (CURB ndash 65 0-1)
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD PO
5 days
Mild to Moderate (CURB ndash 65 2)
Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)
Or Clarithromycin 500mg BD POIV
Mild CURB-65 1 ndash 5 days
Moderate CURB-65 2 - 7 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Severe (CURB ndash 65 ge3)
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV
or
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
Necrotising pneumonia Discuss with Consultant Microbiologist
MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)
7-10 days
Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist
Levofloxacin use only for adults aged 18 years old and over
Aspiration pneumonia
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergy
Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV
5 days Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 17 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Infection Category Antimicrobials Duration and Comments
Tuberculosis
Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis
Refer all cases to Chest Team for diagnosis and management
Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 18 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
B Hospital acquired pneumonia Definition
Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital
Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens
Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis
From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes
(complicating aspiration of upper respiratory tract secretions or gastric contents)
Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)
Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication
Infection Category Antimicrobials Duration and Comments
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 19 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Respiratory Tract Infections contdhellip
Hospital Acquired Pneumonia
Mild
Co-amoxiclav 625mg TDS PO or 12g TDS IV
Penicillin allergic
Clarithromycin 500mg BD POIV
Or
Doxycycline 200mg stat then 100mg PO OD
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
7 days
Severe
Piperacillin-tazobactam 45g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Levofloxacin 500 mg POIV BD +
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
If aspiration likely add
Metronidazole 500mg IV TDS 400mg PO TDS
7-10 days
Alternative during piperacillin-tazobactam supply shortage
As per penicillin allergic
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 20 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
C Chronic Obstructive Pulmonary Disease (COPD) Definition
COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate
Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes
Pathogens
It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla
pneumoniae
The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation
Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD
Dyspnoea (eMRCD)
5a=1 5b=2 DECAF score In hospital mortality
Eosinopenia (lt005)
1 0 0
Consolidation 1 1 15
Acidaemia pHlt73
1 2 54
Fibrillation (atrial) 1 3 153
4 31
5 405
6 50
eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing
Respiratory Tract Infections contdhellip
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 21 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Management
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD
Infection Category Antimicrobials Duration and Comments
Chronic Obstructive Pulmonary Disease
(COPD)
Mild
Amoxicillin 500mg TDS POIV
Penicillin allergy
Doxycycline 200mg stat then 100mg - 200mg OD
7 days
Severe
Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV
Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO
Penicillin allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV
7-10 days
Levofloxacin use only for adults aged 18 years old and over
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 22 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
D Bronchiectasis (non-CF) Definition
A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions
Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions
Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia
Criteria for hospital admission include
Unable to cope at home
Cyanosis or confusion
Febrile temp gt38ordmC
Signs of cardiorespiratory failure
Unable to take oral drugs
Failure to respond to adequate oral therapy or no suitable oral therapy available
Pathogens
Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common
In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)
Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae
Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate
Investigations
All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)
Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result
Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management
Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen
Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 23 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis
Acute exacerbation
(Inpatient) Mild
Amoxicillin 05g -1g TDS IV
Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or
Clarithromycin 500mg PO BD
10-14 days
Acute exacerbation
(Inpatient) Severe
Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously
10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 24 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology
Respiratory Tract Infections contdhellip
Infection Category Antimicrobials Comments
Bronchiectasis Acute exacerbation
(Outpatient)
Amoxicillin 500mg TDS PO
Duration 14 days
2nd
line (failure of 1st linePenicillin allergy)
Doxycycline 100mg BD PO
Duration 14 days
3rd
line (sequential failure of 1st amp 2
nd line
therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days
Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa
Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 25 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
E Non-resolving pneumonia and empyema
Definition
Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation
Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)
Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology
If pleural effusion is seen or suspected on CXR request chest ultrasound
if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture
Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised
Management
All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage
Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated
Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon
Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 26 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Non- resolving pneumonia and
empyema
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
Minimum 3 weeks often requires 6-8 weeks
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 27 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
F Lung abscess and necrotising pneumonia Definition
Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus
In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation
Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly
Pathogens
Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen
o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia
o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group
Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections
Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 28 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
Management
Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)
Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)
Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)
Infection Category Antimicrobials Duration and Comments
Lung abscess and necrotising pneumonia
1st line (IV antibiotics
are always required initially)
Co-amoxiclav 12g TDS IV
Substitute co-amoxiclav with
Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment
Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist
If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +
Metronidazole 500mg IV TDS
2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intra- venous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic
regimen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 29 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Respiratory Tract Infections contdhellip
References
Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf
Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669
httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf
National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish
British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 30 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections
Infection Category Antimicrobials Comments
Abdomino-pelvic sepsis (including
post-operative biliary tree amp Diverticulitis)
For suspected STI-related infection
please see section ldquoGenitourinary
Infectionsrdquo
1st Line
Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Enterococci Anaerobes
Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction
2nd
line therapy is indicated if
- Failure to respond to 1st line antibiotics after 48 ndash 72hr
- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)
- 1st line therapy is contraindicated
- Microbiological cultures reveal resistance to 1st line but sensitivity to
2nd
line antibiotic
Discuss with Consultant Microbiologist if severely unwell or not responding to therapy
Duration Depends on underlying source Discuss with Consultant Microbiologist
2nd
Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +
Ciprofloxacin 400mg BD IV +
Metronidazole 500mg TDS IV
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +
Metronidazole 400mg TDS PO500mg TDS IV
Spontaneous Bacterial Peritonitis
1st Line
Piperacillin-Tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Coliforms Strep pneumoniae Enterococci
Primarily occurs in patients with decompensated cirrhosis with ascites
Duration 5 ndash 7 days
Penicillin allergy Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 31 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Liver Abscess
1st Line
Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Aetiology Coliforms Streptococci Anaerobes
Foreign Travel Consider Entamoeba Hydatid disease
Refer patient to Gastroenterology
Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy
2nd Line
Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV
Penicillin allergy Discuss with Consultant Microbiologist
Suspected Amoebic Liver Abscess
Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 32 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
Necrotising Pancreatitis
Mild ndash Moderate disease without
necrosis Antibiotic therapy is NOT indicated
Aetiology Most cases non-infective
Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection
Duration 7 ndash 14 days
Severe disease with pancreatic necrosis
on CT
Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV
Alternative during piperacillin-tazobactam supply shortage
Discuss with Consultant Microbilogist
Penicillin allergy Discuss with Consultant Microbiologist
Cirrhosis with Acute Variceal Bleeding
1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days
Alternative during piperacillin-tazobactam supply shortage
Co-amoxiclav 12g TDS IV +
Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
Penicillin Allergy Discuss with Consultant Microbiologist
Acute Infective Diarrhoea
(Gastroenteritis)
Antibiotic therapy is NOT routinely indicated
Ensure adequate rehydration (oral or IV)
Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist
Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium
Recent Travel Consider Entamoeba amp Giardia
Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 33 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
GastrointestinalIntra-abdominal Infections contdhellip
Infection Category Antimicrobials Comments
C difficile Infection (CDI)
Refer to
The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)
Mild CDI Metronidazole 400mg TDS PO
Assess severity of CDI each day as follows
Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day
Moderate CDI Associated with a raised WCC that is lt15 109L it is
typically associated with 3ndash5 stools per day
Severe CDI Associated with a WCC gt15 109L or an acute rising
serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity
Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease
Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease
The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist
Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection
Duration 10 ndash 14 days
Moderate CDI Metronidazole 400mg TDS PO
Severe CDI
Vancomycin 125mg QDS PO
High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO
The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered
Life-threatening CDI
Vancomycin 500mg QDS PO
via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 34 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Central Nervous System Infections
Infection Category Antimicrobials Comments
Bacterial Meningitis
Community-acquired
Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology N meningitidis Strep pneumoniae H influenzae
Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised
Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner
Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic
All cases should be notified to Public Health
Duration
N meningitidis ndash 7 days
Strep pneumoniae ndash 10 ndash 14 days
H influenzae ndash 10 days
L monocytogenes ndash 21 days
gt55yrs Pregnant
Immunocompromised
ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist
Post neurosurgical head injury
Discuss with Consultant Microbiologist
CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre
Brain Abscess
1st Line
Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes
Take blood cultures prior to antibiotic therapy
All cases should be discussed with the Consultant Microbiologist and Neurosurgical team
Penicillin allergic Discuss with Consultant Microbiologist
MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)
Viral Encephalitis Aciclovir 10mgkg TDS IV
Aetiology Herpes Simplex Virus Varicella Zoster Virus
Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis
Discuss with Consultant Microbiologist
All cases should be notified to Public Health
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 35 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Bone and Joint Infections
Infection Category Antimicrobials Comments
Septic Arthritis (Native joint no
prosthesis in situ)
1st Line
Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at
risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
N gonorrhoeae likely
Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist
Septic Arthritis (prosthetic joint in
situ)
All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens
Osteomyelitis
1st Line
Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO
Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp
Discuss all patients with Microbiology amp Orthopaedics
Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed
Duration 6 weeks
Penicillin Allergy
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 36 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Endocarditis
Infection Category Antimicrobials Comments
Infective Endocarditis (IE)
In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics
Native valve indolent presentation
Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD
Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis
- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL
See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)
Native valve acute presentation
Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist
Prosthetic valve
Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 37 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis)
Infection Category Antimicrobials Comments
Septicaemia
Clinical source of infection present
See relevant section of this guideline for antimicrobials targeted against the clinical source of infection
Clinical source of infection unknown ndash Community onset
1st Line Co-amoxiclav 12g TDS IV +
Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
2nd
Line Piperacillin-tazobactam 45g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection
- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4
See Trust Policy for Managing Sepsis 2
nd Line therapy is indicated if - Failure to respond to 1
st line therapy
- Microbiology results indicated resistance to 1st line but
susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate
gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)
Discuss with Consultant Microbiologist if not responding to empirical regimen
Clinical source of infection unknown ndash Hospital onset
1st Line Piperacillin-tazobactam 45g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 38 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Septicaemia (including Neutropenic Sepsis) contd
Infection Category Antimicrobials Comments
Neutropaenic Sepsis Community amp Hospital
onset
1st Line Piperacillin-tazobactam 45g
QDS IV
Penicillin allergic (MILD eg rash)
Meropenem 1g TDS IV
Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO
See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection
Catheter-related Blood Stream
Infection (CRBSI)
Peripheral Venous Cannula (PVC)
See section Skin amp Soft Tissue Infection
Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 39 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ear Nose amp Throat (Oropharyngeal) Infections
Infection Category Antimicrobials Comments
Streptococcal Pharyngitis Tonsillitis
1st Line
Penicillin V 500mg QDS PO
Unable to swallow Benzylpenicillin 12g QDS IV
Aetiology Commonly viral Group A Streptococcus
Most ENT infections are viral for which antibiotics are NOT indicated
Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Bacterial Sinusitis
1st Line
Outpatient Amoxicillin 500mg TDS PO
Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV
Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes
Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Otitis Media 1
st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae
Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV
Acute Epiglottitis
Ceftriaxone 2g OD IV
Severe penicillin allergy Discuss with Consultant Microbiologist
Aetiology H influenzae Strep pneumoniae Staph aureus
Do NOT attempt a throat swab ndash risk of airway obstruction
Refer to ENT
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 40 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Ophthalmic Infections
Infection Category Antimicrobials Comments
Conjunctivitis 1st Line
Chloramphenicol 0middot5 eye drops
One drop at least every 2 hours reducing frequency as infection is controlled
The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis
Duration Continue for 48hr after resolution
Suspected herpetic conjunctivitis Refer to Ophthalmologist
Contact Lens Keratitis
Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba
Refer to Ophthalmologist
OrbitalPeriorbital Cellulitis
1st Line
Co-amoxiclav 12g TDS IV
MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter
Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)
Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present
Duration 7 ndash 14 days Penicillin allergic
Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO
Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist
Ophthalmic ZosterHSV
Aciclovir 800mg 5 times daily PO
+ topical Aciclovir eye ointment 3 applied 5 times daily
Aetiology VZV HSV
Refer to Ophthalmologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 41 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases
Infection Category Antimicrobials Comments
Gonococcal Infection
1st Line
Ceftriaxone 500mg IM STAT
+ Azithromycin 1g PO STAT (single dose)
Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic
If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected
2nd
Line
(IM injection contraindicated or refused by patient)
Cefixime 400 mg PO STAT
+ Azithromycin 1g PO STAT (single dose)
Chlamydia
1st Line Doxycycline 100mg BD PO for 7 days
Alternative
Azithromycin 1g PO STAT (single dose)
[Reserved if concerns regarding poor compliance]
Epididymo-orchitis
lt35yrs sexually active
STD likely
Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO
Aetiology N gonorrhoea Chlamydia trachomatis
Refer to the GUM clinic
Duration 10 ndash 14 days
gt35yrs not sexually active
STD unlikely
Outpatient
Ciprofloxacin 500mg BD PO
Inpatient
Piperacillin-tazobactam 45g TDS IV
Aetiology Coliforms
Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV
Prostatitis
1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually
active N gonorrhoea Chlamydia trachomatis
Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days
Alternative (intolerant of 1
st line)
Trimethoprim 200mg BD PO
If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 42 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Genitourinary Tract Infections Sexually Transmitted Diseases contd
Infection Category Antimicrobials Comments
Pelvic Inflammatory
Disease
Outpatient
Ceftriaxone 500mg IM STAT
followed by
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci
Anaerobes
Refer to Obs amp Gynae
If pregnant these regimens are NOT suitable Please discuss with
Consultant Microbiologist
Duration 14 days
Inpatient
Ceftriaxone 2g OD IV +
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Once afebrile 24hr with sustained clinical
improvement switch to
Doxycycline 100mg BD PO +
Metronidazole 400mg BD PO
Severe Penicillin
allergy
Ofloxacin 400mg BD POIV +
Metronidazole
400mg BD PO500mg TDS IV
High risk of gonococcal infection Discuss
with Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 43 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY
General Considerations 1 Effective prophylaxis
Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)
Should be given intravenously in a fully therapeutic dose
Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)
2 An additional intra-operative dose should only be considered if the operation
Is long (gt5 hours)
Involves substantial blood loss (gt15L)
Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period
Is no more effective for preventing surgical site infections than a single preoperative dose
Encourages the emergence of resistant bacteria (eg MRSA and VRE)
Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal
function Discuss with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 44 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GASTROINTESTINALINTRA-ABDOMINAL
1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal
Co-amoxiclav 1middot2g IV at induction
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
2 Laparoscopic cholecystectomy
Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage
Gentamicin 120mg IV single dose at induction
3 Gastrointestinal endoscopy
As per BSG Guidelines (2009)
- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10
9L) AND procedure is
considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just
before procedure
4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis
Piperacillintazobactam 2middot25g IV single dose just before the procedure
Alternative during piperacillin-tazobactam supply shortage
Ciprofloxacin 400mg stat dose before procedure
Penicillin allergy Gentamicin 120mg IV
5 PEG insertion
Co-amoxiclav 1middot2g IV just before the procedure
Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 45 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
GENITOURINARY
If preoperative urine is positive treat according to culture result for 48 hrs before operation
1 Cystoscopy
Rigid cystoscopy Gentamicin 120mg IV just before procedure
Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above
2 Urodynamics Trimethoprim 200mg PO bd 37
3 Transrectal ultrasound scan (TRUS) and biopsy of prostate
Ciprofloxacin 1g PO just before procedure
Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure
4 Transurethral resection of
prostate (TURP)
Transurethral resection of bladder tumour (TURBP)
Open renal surgery
Radical retropubic prostatectomy
Stent insertionchangeremoval
Stone removal (open)
Shock wave lithotripsy
Gentamicin 120mg IV at induction
(if CSUMSU positive treat according to sensitivity)
8 Radical perineal prostatectomy
Co-amoxiclav 1middot2g IV TDS for 48 hours
Penicillin allergic discuss with Consultant Microbiologist
9 Cystectomy + ndash reconstruction
Gentamicin 120mg IV plus Metronidazole 1g PR at induction
Followed by Metronidazole 1g PR12 hours post procedure
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 46 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
OBSTETRIC amp GYNAECOLOGICAL SURGERY
1 Vaginal abdominal or laparoscopic hysterectomy
Co-amoxiclav 1middot2g IV at induction
A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)
Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV
MRSA Colonised ADD Teicoplanin 400mg IV
2 Termination of pregnancyERPC
Metronidazole 1g PR at induction
Followed by
Doxycycline 100mg BD for 7 days
OR
Azithromycin 1g PO stat (use only if likely poor compliance
unless patient was screened negative for chlamydia)
3 Trans vaginal tape Gentamicin 120mg IV single dose at induction
4 Caesarean section Refer to Caesarean Section Guideline no 427
5 Prevention of perinatal infection with Group B Streptococcus
Refer to Departmental guidelines
PLASTIC AND RECONSTRUCTIVE SURGERY
1 Clean surgery
Antibiotic prophylaxis not routinely required
Extensivelengthy operations (gt3hr) graft of prosthetic surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
2 Clean Contaminated surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 47 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS
ORTHOPAEDIC
1 Clean orthopaedic surgery without implant
Antibiotic prophylaxis is NOT routinely recommended
2 Bone surgery
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
3 Prosthetic joint surgery
Primary arthroplasty
Single stage revision arthroplasty
(infection not suspected)
Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV
These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life
If infection possible take ge5 samples before giving prophylaxis
These regimens may need modification to cover resistant pathogens in individual cases
Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist
NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives
4 Compound fracture repair
Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 48 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Repeat all three 12 hours later
5 Amputation
For prevention of gas gangrene in high (lower limb) amputations or following major trauma
Benzylpenicillin 600mg QDS IV for 5 days
Penicillin allergy Metronidazole 500mg TDS IV for 5 days
VASCULAR SURGERY
All Vascular Surgical Procedures
Co-amoxiclav 1middot2g IV at induction
MRSA colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction
Vascular graft Continue antibiotics for 24 hours post-op
Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery
THORACIC and HEAD amp NECK SURGERY
Thoracic Surgery
Head amp Neck Surgery
Co-amoxiclav 1middot2g IV at induction
MRSA Colonised ADD Teicoplanin 400mg IV
Penicillin allergy Teicoplanin 400mg IV
plus Gentamicin 120mg IV at induction
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 49 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
6 OTHER ANTIBIOTIC PROPHYLAXIS
OTHER ANTIBIOTIC PROPHYLAXIS
PROCEDURE RECOMMENDED ANTIMICROBIALS
1 Endocarditis prophylaxis for patients with structural cardiac conditions
(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)
Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)
EXCEPT
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis
(Discuss with a Consultant Microbiologist)
2 Permanent Pacemaker Insertion
Refer to the current Department Guideline
For
Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults
CARD 018
Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)
A second dose of Flucloxacillin 1g IV should be given
intra-operatively if procedure lasts ge 2 hours
Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min
prior to procedure)
Second dose of Teicoplanin not required as very long
half-life
Comments
Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)
Post-procedure antibiotics are not necessary
Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated
3 Splenectomy or dysfunctional spleen
Penicillin V 500mg PO bd (life long)
Penicillin allergy Erythromycin 500mg PO od (life long)
Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 50 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 51 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 1
Guideline for Switch Antibiotic Therapy
Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with
Increased patient convenience (eg increased mobility comfort and quality of life)
Ease of administration
Reduced hospital resources (eg nursing time drug costs consumables IV equipment)
Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)
Earlier patient discharge
IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days
Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription
House Officers and Senior House Officers may switch IV to oral therapy
Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile
The patient is able to take oral medication
Clinically the patient is improving satisfactorily
An equivalent oral formulation is available
If in doubt contact Consultant Microbiologist for advice
There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav
(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 52 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Exclusions from Switch Therapy
Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as
Endocarditis
Meningitis
Septicaemia
Osteomyelitis
Septic arthritis
Cellulitis with spreading lymphadenopathy and high fever
Encephalitis
Infective gangrene
Peritonitis
Neutropenia
Line sepsis
Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as
Severe mucositis
Ileus
Protracted vomiting
Severe diarrhoea
Malabsorption syndromes
Nasogastric suctioning
NB This list is not exhaustive
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 53 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 2
Penicillin Allergy
a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-
Lactam Hypersensitivity and Cross-Reactivity)
Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin
b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned
c) In serious infections or if you are unsure always discuss with Consultant Microbiologist
General Points on Allergies
The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts
Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status
Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber
Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc
If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed
If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated
The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments
Patients identified as having a drug allergy should wear an allergy wristband
All wristbands should be checked BEFORE any drug is administered
On no account may allergy bands be used as name bands
A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic
Patients should be informed if they are known or suspected to have developed a drug allergy
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 54 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Beta-lactam antibiotics
Amoxicillin
Benzylpenicillin (Penicillin G)
Co-amoxiclav (Augmentinreg)
Flucloxacillin
Phenoxymethylpenicillin (Penicillin V)
Piperacillin plus tazobactam (Tazocinreg)
Pivmecillinam
Temocillin
CONTRA-INDICATED History of penicillin allergy
with life threatening reaction eg anaphylaxis
angioedema immediate
rash urticaria
CAUTION History of non-severe penicillin
allergy
eg Delayed or minor rash
Avoid if severe penicillin allergy- anaphylaxis
angioedema urticaria
CONSIDERED SAFE
In patients with penicillin
allergy however consider
allergies to other drugs
Cephalosporin and beta-lactam antibiotics
Cefaclor Aztreonam Cefadroxil Meropenem
Cefalexin Ertapenem
Cefixime
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Other antibiotics Gentamicin
Azithromycin Levofloxacin Ciprofloxacin Linezolid
Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin
Daptomycin Tobramycin
Erythromycin Trimethoprim
Fosfomycin Vancomycin
Please check BNF
for a full list of
these antibiotics
PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients
ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of
medicine and the type of allergic reaction
Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate
hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic
If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)
or Antimicrobial Pharmacist (bleep 5933)
(Adapted from Luton and Dunstable NHS Trust)
ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED
IN ALL CASES
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 55 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 3
Protocol for Vancomycin Administration in Adults
Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required
Dose and
Monitoring
Normal adult dose (normal renal function) is 1g BD
Check pre-dose (trough) level before the 4th dose
The 4th dose should be given while awaiting results
If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist
For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours
For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose
If the vancomycin level is lt15mgL give the next dose
If vancomycin level 15mgL contact Consultant Microbiologist
Administration
Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5
Rate should not exceed 10mg per minute
Reference
Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 56 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 4
Teicoplanin dose banding in adults with good renal function
Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections
Intra-abdominal Infections Septicaemia Neutropenic sepsis
Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose
ge80 1000mg 12 hourly for 3 doses 1000mg once a day
65-799 800mg 12 hourly for 3 doses 800mg once a day
50-649 600mg 12 hourly for 3 doses 600mg once a day
le499 400mg 12 hourly for 3 doses 400mg once a day
Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery
Actual body weight (Kg) Single dose
ge80 1000mg (needs to be given as an infusion see below)
65-799 800mg
50-649 600mg
le499 400mg
Actual body weight (Kg) Loading dose Maintenance dose
ge145 1000mg 12 hourly for 3 doses 1000mg once a day
110-1449 800mg 12 hourly for 3 doses 800mg once a day
75-1099 600mg 12 hourly for 3 doses 600mg once a day
le749 400mg 12 hourly for 3 doses 400mg once a day
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 57 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Therapeutic Dose Monitoring for Teicoplanin
Loading dose See table
Maintenance dose See table
Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use
Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes
Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results
Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL
Dose adjustment (always check is level is true trough level before interpreting the result)
Trough level Dose adjustment Comment
˂20mgmL Increase dose by one dose band
Re-assay after 5 days
NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL
20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function
˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose
Re-assay in 5-7 days
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 58 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Further reading
Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]
Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 59 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 5
Adult Extended Interval Gentamicin dose Dosing
See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 60 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6
Adult Extended Interval Amikacin Dosing
1 General Principles
All IV antibiotics should be reviewed after 48 hours
Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist
The patientsrsquo weight and renal function is required for dose determination
eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose
11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below
Known renal impairment
Patients gt75yrs of age
Pregnancy
Patients with extensive burns (gt20 of body surface area)
Blind patients
Patients with endocarditis
Patients with a history or signs of hearing loss or vestibular dysfunction
Patients with a family history of maternal early-onset deafness
Patients with myasthenia gravis
Patients known to be hypersensitive to aminoglycosides or excipients
12 Determine the weight for dosing
For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)
13 Determine the renal function for dosing
Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation
Use actual body weight or adjusted body weight if BMIgt25
Male patient Female patient
CrCl= (140-age (years)) x weight (Kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age (years)) x weight (Kg) x 1middot04
Serum creatinine (micromoll)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 61 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 62 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
2 Amikacin Therapy
21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg
22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1
23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)
Table 1 Dose interval and monitoring for amikacin based on calculated CrCl
Renal function
Initial IV amikacin dose Monitoring
CrCl ge40mlmin
15mgKg every 24 hours
Max dose 1300mg
Take trough level before 2nd dose then give the 2nd dose
Check result BEFORE giving 3rd dose
If the level lt5mgL give the 3rd dose and monitor levels twice weekly
If the level ge 5mgL check the level every 12-24
hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing
therapy
CrCl 30-39mlmin
15mgKg every 36 hours
Max dose 1300mg
CrCl 20-
29mlmin
15mgKg every 48 hours
Max dose 1300mg
CrCl lt20 mlmin
75mgKg stat
Take trough level 24 hours later Check result before next dose
Only give next dose if level lt5mgL Repeat this daily
Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight
24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 63 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
APPENDIX 6a
Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients
Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose
Male patient Female patient
CrCl= (140-age) x weight (kg) x 1middot23
Serum creatinine (micromoll)
CrCl = (140-age) x weight (kg) x 1middot04
Serum creatinine (micromoll)
The weight used for calculating creatinine clearance will be based on BMI as below
BMI (kgm2) Weight to use when calculating Creatinine
Clearance
lt 185 ndash 249
Actual Body Weight (ABW)
gt25 Adjusted Body Weight (AdjW)
Ideal Body Weight (IBW)
Males IBW = 50 kg + 23 kg for each inch over 5 feet
Females IBW = 455 kg + 23 kg for each inch over 5 feet
Adjusted Body Weight (AjBW)
IBW + 04(actual weight - IBW)
Estimated Ideal Body Weight (IBW)
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given
ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust
All dosage recommendations are for adults and assume normal renal and liver function
Authors Dr Qaiser et al Date of issue December 2017 Page 64 of 64 CGSG Registration No 008 Version No 17 Review before December 2020
Sending Samples to Pathology Laboratory
8 FURTHER READING
Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12
The sample should be marked as URGENT Urgent samples will be processed within 1 hour
therefore please ensure the trough level is obtained 2 hours before the next dose so that a
level is obtained on time before the next dose can be given