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INFECTIONS 5.1 ANTIBACTERIAL TREATMENT: GENERAL PRINCIPLES N.B. This list is not exhaustive and cannot cover every presentation of an infectious disease; if an infection is not listed please seek advice from microbiology. Antimicrobial therapy may need to be modified, particularly in the context of immunosuppression, MRSA carriage, prior antimicrobial therapy or foreign travel. If no improvement in the patient’s condition is seen within 48-72 hours, contact microbiology for advice. The reasons for the existence of these antimicrobial prescribing guidelines are numerous. The Standing Medical Advisory Committee issued guidelines on the topic of antimicrobial resistance in September 1998. The issues highlighted by this committee and thus built into our guidelines were as follows: Antibiotic use selects for resistant bacteria. Resistant bacteria accumulate and spread Resistance increase clinical complications, lengthens hospital stay and adds cost Development of new antibiotics is slow, expensive and cannot be guaranteed With more resistance and few new antimicrobial agents, modern medicine is threatened. Antibiotic usage can result in antibiotic associated diarrhoea and Clostridium difficile infection 5.1.1 Choosing antibiotics In choosing an appropriate antibiotic, the following factors must be considered: Underlying pathology Clinical presentation and site of infection Micro-organisms involved (actual / suspected) Patient characteristics Allergy Renal and hepatic function Previous micro-organisms resistant to antibiotics Females – pregnancy / breastfeeding Concomitant drug therapies Age Duration of therapy, dose and route of administration – depends on site, type and severity of infection, and response to treatment. Intravenous therapy is required for life threatening infections. However, the risk and expense of intravenous therapy should be avoided where possible. Guidelines for appropriate conversion of intravenous to oral antibiotic treatment are detailed overleaf. 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 1 of 22 INFECTIONS 5.1.2 Prescribing Indication The indication for treatment must be documented on the drug chart and in the patient’s notes. Where this is considered inappropriate due to patient confidentiality, indication must still be recorded in the notes. In this case “Refer to notes” should be written in the Indication / additional information section of the drug chart. Duration Duration of prescription should always be documented on the drug chart and in the patient’s notes. Pharmacists will cross off the antimicrobial once the prescription is complete. Nurses should not administer any medication once the prescribed duration has been exceeded, as this is no longer a valid prescription. 5.1.3 Patient Counselling Inpatients Patients or their legal guardians should be informed: that an antimicrobial agent has been prescribed, and the reason why it is necessary Risks and side effects explained At discharge Patients or their legal guardians should be informed: they have been prescribed an antimicrobial to take home and the reason why an antimicrobial is necessary the course length and the importance of completing the course possible risks and side effects of the antimicrobial therapy, and what to do if they develop at home 5.1.4 Automatic STOP Orders Pharmacists will attach “automatic STOP order” stickers to prescriptions for oral Antibiotics where appropriate to prevent administration for longer than 7 days. If the doctor requires treatment to be continued for longer than 7 days, he/she must rewrite the prescription. Automatic STOP order stickers will not be attached for the treatment conditions, which require prolonged antibacterial therapy, such as Tuberculosis, sub-acute Bacterial Endocarditis and Osteomyelitis. 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 2 of 22 INFECTIONS 5.2 IV TO ORAL ANTIMICROBIAL THERAPY SWITCH POLICY Introduction IV to oral switch is the punctual conversion of IV antibiotic therapy to an effective oral dose. Patients may be considered for switching IV to oral therapy once the patient has shown clinical improvement and medically stable. Patients who present with a severe infection and initially require IV therapy can be switched to oral therapy within 48 hours, provided that the patient is adequately absorbing oral medication. Studies have shown that there a number of advantages to support the IV to oral switch. Reduced risk of hospital acquired bacteraemia and infected IV lines Saves both medical and nursing time Reduces discomfort for patients Facilitates possible discharge from hospital earlier Possible cost reduction Patient is more likely to receive antibiotics at correct time Reduced risk of administration errors The acronym COMS (see below for details) provides advice whether a patient is suitable to be converted to oral therapy. When to switch? Considerations for the early switch to oral therapy COMS 1, 2, 3, 4 Patient should be reviewed at 24 – 48 hours C Clinical improvement observed O Oral route not compromised (vomiting, malabsorptive disorder, NBM, swallowing difficulties, unconscious, severe diarrhoea) NB: if NG/PEG feeding then please consult your pharmacist. M Markers showing a trend towards normal Apyrexial: Temp > 36oC and <38oC for at least 24 hours BP stable Plus NOT more than one of: Heart rate >90 beats/min Respiratory rate >20 breaths/min WCC <4 or >12 (WCC should show a trend towards normal: absence of such should not hinder switch if all other criteria met and not neutropenic S Specific indication/deep-seated infection (refer to table 1) High risk/deep-seated infections Certain infections may appear to respond rapidly to intravenous therapy, but sometimes they require persistent IV therapy. This assures that sufficient drug levels are attained at the site of infection and to optimise the response and prevent relapse. Discuss with microbiology before switching patients with high risk/deep seated infections to oral therapy. 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 3 of 22 INFECTIONS Table 1 Deep seated infections that may require High risk infections requiring prolonged an initial two weeks of IV therapy IV therapy Liver abscess Staphylococcus aureus bacteraemia Osteomyelitis Severe necrotising soft tissue infections Septic Arthritis Severe infections during chemotherapy Empyema related neutropaenia Cavitating pneumonia Infected implants/prosthesis Meningitis/encephalitis Intracranial abscesses Mediastinitis Endocarditis Exacerbation of cystic fibrosis / bronchiectasis Inadequately drained abscesses or empyema Candidaemia If you have any queries please contact Microbiology. Pharmacists IV to oral antibiotic switch policy: Pharmacists within Basildon and Thurrock University Hospitals NHS Foundation Trust have the authority of the Medicines Management Committee to change intravenous antibiotics to oral. This must in accordance with the above guidelines, and only where appropriate. Documentation in the patients’ notes will bring this to the attention of the medical / surgical team. 5.3 ANTIBIOTIC INTRAVENOUS TO ORAL CONVERSION GUIDELINES Intravenous Amoxicillin Flucloxacillin Benzylpenicillin Clarithromycin Co-amoxiclav Metronidazole Piptazobactam (Tazocin®), Vancomycin, Meropenem, Gentamicin, Teicoplanin Oral Amoxicillin 500mg-1g TDS Flucloxacillin 500mg – 1g QDS Amoxicillin 500mg-1g TDS Clarithromycin 500mg BD Co-amoxiclav 625mg TDS Metronidazole 400mg TDS Seek advice from Microbiology Exemptions to these guidelines are for the Intensive Care Unit (ITU) and Neonatal Intensive Care Unit (NICU). 5.4 CIRCUMSTANCES WHERE ANTIBIOTICS ARE OFTEN NOT REQUIRED 1. 2. 3. 4. Venous leg ulcers Pressure sores Colonising flora in upper respiratory tract Diarrhoeal disease 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 4 of 22 INFECTIONS 5.5 ANTIBIOTIC COMBINATIONS Never use either of the following as a single agent: Sodium fusidate Rifampicin Unnecessary combinations: This applies to the majority of cases of infection. Some patients with serious or complex infections which have failed previous therapy may require combinations. Contact Microbiology. Unnecessary Combination Co-amoxiclav (Augmentin®) / Piperacillin & tazobactam (Tazocin®) plus Metronidazole Benzylpenicillin plus Cephalosporin Flucloxacillin plus Vancomycin Cephalosporin plus Broad-spectrum penicillin/ Quinolone 5.6 Rationale The former covers anaerobes adequately, except for Clostridium difficile. (Metronidazole may be added in exceptional circumstances). For CNS infections, use culture sensitivities to rationalise treatment as soon as possible. Cross off Flucloxacillin if MRSA isolated. Vancomycin will cover majority of pathogens covered by Flucloxacillin Unless indicated by microbiology ALLERGIES Hypersensitivity reactions are the common form of adverse events with penicillin. There are 2 main types – immediate and delayed. Severe Allergy (Immediate reactions) – These result in a patient suffering from anaphylaxis, angioedema or an immediate type of urticarial rash. Patients who suffer from severe allergies should avoid all penicillins, cephalosporins and carbapenems. Mild Allergy (Delayed reactions) – These result in the patient suffering from a rash, which sometimes can appear 7-10 days after therapy. Patients who suffer mild allergies should avoid pencillins. Cephalosporins and carbapenems can be used but caution should be exercised because of cross-sensitivity. Penicillin allergy • True anaphylactic penicillin allergy is rare. • Approximately 10% of patients who develop a rash with penicillin will also develop a similar reaction to cephalosporins. There is no increased risk of anaphylaxis in this patient group. • Refer to table below for guidance. If in doubt contact pharmacy or microbiology. 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 5 of 22 INFECTIONS Drug use in penicillin rash allergy DO NOT USE Amoxicillin Benzylpenicillin Co-amoxiclav (Augmentin®) Flucloxacillin Penicillin v (Phenoxymethylpenicillin) Piperacillin + Tazobactam (Tazocin®) Temocillin Ticarcillin + clavulanic acid (Timentin®) Use with CAUTION Aztreonam Cefradine Cefotaxime Ceftazidime Imipenem with Cilastatin (Primaxin®) Meropenem Can Use Azithromycin Doxycycline Clarithromycin Erythromycin Minocycline Gentamicin Clindamycin Sodium Fusidate Vancomycin Teicoplanin Linezolid Co-trimoxazole Trimethoprim Metronidazole Ciprofloxacin Nitrofurantoin Antimicrobials that should not be used in true penicillin allergy are coloured red in this formulary. Those that should be used with caution are orange. 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 6 of 22 INFECTIONS 5.7 BLOOD: SEPTICAEMIA: “BLIND” TREATMENT OF INFECTION Clinical features: Fever, rigors, mental confusion, tachycardia, and hypotension. Action: Take blood cultures before initiating antibiotics Establish primary source of sepsis Consider likely pathogens Consider the patient’s underlying pathology NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Possible cause Source unknown Non-blanching rash / purpura present Likely micro-organisms Escherichia coli, Staphylococcus aureus, Streptococcus pneumoniae Antibiotics Penicillin Allergy Piperacillin + Tazobactam (Tazocin®) 4.5g TDS IV + Gentamicin 5mg/kg stat Neisseria meningitidis Ceftriaxone 2g IV BD Mild allergy Meropenem 1g TDS IV + Gentamicin 5mg/kg IV OD Severe allergy – Ciprofloxacin 400mg IV BD + Teicoplanin 400mg IV BD for 3 doses then 400mg IV OD + Gentamicin 5mg/kg IV Chloramphenicol 1g IV QDS Discuss all cases with microbiology 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 7 of 22 INFECTIONS 5.8 BONE AND JOINT Comments A microbiological assessment should be attempted before commencement of antibiotic therapy. Therapy is likely to be prolonged – 6 weeks to 6 months (please state this on drug chart / prescription) MRSA likely. Bone and Joint antibiotic therapy should only be given after a microbiological cultures has been taken (joint fluid/blood cultures) Review antibiotics when culture results are available Please note that a separate policy is available for diabetic foot infections NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Antibiotics Osteomyelitis Septic Arthritis Flucloxacillin 1-2g QDS IV + Sodium Fusidate 500mg TDS PO Benzylpenicillin 1.2g IV QDS + Flucloxacillin 1g IV QDS Penicillin Allergy / MRSA Teicoplanin 400mg IV BD for 3 doses then 400mg IV OD and Sodium Fusidate 500mg TDS PO Add Gentamicin if systemically unwell. Allergy or MRSA – Teicoplanin 400mg IV BD for 3 doses then OD + Clindamycin 600mg IV QDS Consult microbiology if patient ≥65 Comments Duration if acute 42 days Duration if chronic 90 days Duration of at least 28 days If adolescent septic arthritis, or if gonococcus is suspected, add Ceftriaxone 2g IV OD and discuss with microbiology. Ensure urethral/cervical swabs are obtained prior to starting antibiotics if gonococcus suspected Prosthetic Joint Infection Discontinue clindamycin immediately if diarrhoea develops and discuss with microbiology No empirical treatment is required unless patient acutely unwell. All cases must be discussed with microbiology 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 8 of 22 INFECTIONS 5.9 CARDIOVASCULAR Comments Blood cultures are essential 3 sets of blood cultures must be taken prior to initiation of therapy All cases should be discussed with microbiology NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Endocarditis – Acute presentation (Native valve) Prosthetic valve (await cultures) Sternal wound infection (Mild) Severe sternal wound infection/ Mediastinitis 5.10 Antibiotics Benzylpenicillin 1.2g 4 hourly IV + Gentamicin 1mg/kg IV TDS + Flucloxacillin 2g IV QDS Vancomycin 1g IV BD + Rifampicin 300600mg PO/IV BD + Gentamicin 1mg/kg IV TDS Flucloxacillin 500mg1g PO QDS Meropenem 1g TDS IV + Teicoplanin 400mg IV BD for 3 doses then OD Penicillin Allergy Vancomycin 1g BD IV plus Gentamicin 1mg/kg IV TDS Comments If presentation is indolent benzylpenicillin and gentamicin should be sufficient Vancomycin and gentamicin are both nephrotoxic. Monitoring is essential Clarithromycin 500mg PO BD Anaphylaxis – refer to microbiology CENTRAL NERVOUS SYSTEM NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Community – acquired meningitis All patients Community – acquired meningitis Antibiotics Penicillin Allergy Comments (Severe) Ceftriaxone 2g Chloramphenicol Routine administration of antiviral IV BD 1g IV QDS treatment to patients with pure meningitis is not indicated. If there is evidence of encephalitis or meningoencephalitis add Aciclovir 10mg/kg TDS Add Contact Amoxicillin 2g microbiology Review treatment in light of CSF 4o IV cultures and PCR results Age >55, pregnancy, immunosuppre ssed, if listeria suspected 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 9 of 22 INFECTIONS 5.11 DENTAL / MAXFAX NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Dental abscess 5.12 Antibiotics Co-amoxiclav 625mg TDS Penicillin Allergy Clindamycin 300mg QDS Consult microbiology if patient ≥65 Comments Discontinue clindamycin immediately if diarrhoea develops and discuss with microbiology EAR, NOSE AND THROAT NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Antibiotics Otitis Externa Topical Gentamicin Topical Ciprofloxacin if Pseudomonas isolated Amoxicillin 1g Clarithromycin PO TDS 500mg PO BD Ceftriaxone 2g Contact micro IV BD Consult microbiology Penicillin V Clarithromycin 500mg PO QDS 500mg PO BD Benzylpenicillin Clindamycin 1.2g IV QDS + 600mg IV Metronidazole QDS. 500mg IV TDS Consult microbiology if patient ≥65 Otitis Media Mastoiditis (acute) Mastoiditis (chronic) Mild suspected bacterial sore throat Pharangitis/tonsillitis (in-patient) Penicillin Allergy Comments Severe infection / malignant disease / diabetes / immunosuppressed – contact microbiology Urgent ENT review needed Discontinue clindamycin immediately if diarrhoea develops and discuss with microbiology If paratonsillar abscess / Ludwigs angina / Vincents angina suspected discuss with microbiology 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 10 of 22 INFECTIONS 5.13 EYE Infection Conjunctivitis 5.14 Antibiotic Chloramphenicol eye drops/ointment GENITAL NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Acute Pelvic inflammatory Disease Antibiotic Ceftriaxone 2g IV stat + Doxycyline 100mg PO BD+ Metronidazole 400mg TDS PO Penicillin Allergy If severe penicillin allergy discuss with Microbiology. NB. Gonococcal resistance is increasing. Outpatient treatment should be discussed with GU Medicine/Microbiology Treatment of retained products of conception Chorioamnitis Co-amoxiclav 625mg TDS PO Co-amoxiclav 1.2g TDS IV Consult microbiology Mild allergy Ceftriaxone 2g IV OD + Metronidazole 500mg IV TDS Severe allergy – Ciprofloxacin 400mg IV BD + Clindamycin 600mg IV QDS 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 11 of 22 Comments Total duration 14 days INFECTIONS 5.15 GASTROINTESTINAL NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Category Antibiotic Acute Gastroenteritis Mild Usually none required as selflimiting Send stool sample and await cultures Co-amoxiclav 1.2g IV TDS ± Gentamicin 5mg/kg stat Moderate – severe Biliary tract Infections, pancreatitis, liver abscess, cholescysitis, peritonitis, diverticulitis, bowel perforation, appendicitis, peri-anal abscess Cholangitis, previous ERCP or stent insertion, hospital acquired intra-abdominal sepsis Helicobacter pylori Eradication Pancreatitis Penicillin Allergy Comments If antibiotics required discuss with microbiology Metronidazole 500mg IV TDS + Ciprofloxacin 400mg IV BD ± Gentamicin 5mg/kg IV OD∗ Tazocin® 4.5g IV TDS +/Gentamicin 5mg/kg stat Total duration 7-14 days Identify and eliminate source; drain any collection Metronidazole 500mg IV TDS + Ciprofloxacin 400mg IV BD ± Gentamicin 5mg/kg IV OD∗ Amoxicillin 1g BD Metronidazole + Clarithromycin 400mg BD + 500mg BD + Clarithromycin Lansoprazole 500mg BD + 30mg BD for 7/7 Lansoprazole 30mg BD for 7/7 Antimicrobial therapy not routinely indicated, but may be required in complicated / severe cases e.g. necrosis. Discuss with microbiology / gastroenterology. 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 12 of 22 INFECTIONS NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Clostridium difficile Category First presentation Second presentation / failed Metronidazole (no improvement after 3 days treatment) ∗ Antibiotic Metronidazole 400mg PO TDS Vancomycin 125mg PO QDS Comments Treatment required for at least 1014 days. If strict Nil by Mouth or Paralytic Ileus, use Metronidazole 500mg IV TDS. All symptomatic patients will be reviewed at least weekly by the multidisciplinary infection prevention and control team Refer to separate Once Daily Gentamicin guidelines for prescribing information 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 13 of 22 INFECTIONS 5.16 RESPIRATORY NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Bronchiectasis Category Antibiotics Tazocin® 4.5g IV TDS Doxycycline 100mg BD PO Pencillin Allergy Comments Ciprofloxacin 500mg -750mg BD PO Infective No CxR N/A For 7 days. exacerbation of changes If intolerant to COPD tetracyclines amoxicillin can be used Community – Mild Amoxicillin 500mg Clarithromycin For 5-7 days acquired (CURB-65 -1g PO TDS 500mg PO BD depending on Pneumonia score 0-1) response CURB – 65 Moderate Amoxicillin 500mg Clarithromycin For 7-10 days score (CURB-65 -1g PO TDS AND 500mg PO BD depending on Confusion AMT score 2) Clarithromycin response ≤8 500mg PO BD Urea ≥ 7mmol/l For 10-14 days. Severe Co-amoxiclav Mild allergy Respiratory Rate (CURB-65 1.2g IV TDS AND Meropenem 1g TDS Discuss with ≥ 30 microbiology score 3-5) Clarithromycin or Ertapenem 1g Blood pressure 500mg PO/IV BD OD + Clarithromycin ≤90/60 500mg PO BD Age >65 Severe allergy Teicoplanin 400mg IV BD for 3 doses then OD + Clarithromycin 500mg PO BD ® Hospital Patients Tazocin 4.5g IV For 5-7 days Mild allergy acquired who have TDS Meropenem 1g TDS according to pneumonia been in >48 clinical response Severy allergy hours Teicoplanin 400mg N.B. Check MRSA IV BD for 3 doses status then OD + Gentamicin 5mg/kg IV OD∗ Co-trimoxazole IV Alternative Pneumocystis 120mg/kg/day in Clindamycin jirovecii 2-4 divided doses 600mg QDS + (Pneumocystis Primaquine carinii) 30mg OD. Discuss with microbiology/ respiratory team.* *Adjunctive Steroids (Prednisolone 40mg BD x5/7, then 20mg BD x5/7, then 20mg OD x11/7) are recommended, at the initiation of treatment, for all patients with HIV associated Pneumocystis and a PaO2 < 9.3 kPa (70mmHg) on air. For those patients with non-HIV related Pneumocystis, the benefit of steroids is less certain but use should be considered on a case by case basis. 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 14 of 22 INFECTIONS NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Category Aspiration Pneumonia (Hospital acquired) Empyema/Lung abcess Cystic Fibrosis Tuberculosis ∗ Pencillin Allergy Levofloxacin 500mg IV BD Legionella pneumophilia Aspiration Pneumonia (Community acquired) Antibiotics Mild – moderate (oral treatment) Severe (intravenous treatment) Amoxicillin 500mg PO / IV TDS + Metronidazole 400mg PO / IV TDS Tazocin® 4.5g IV TDS Comments If severe add rifampicin after discussing with microbiology Most cases of aspiration pneumonia cause a chemical pneumonitis rather than infection Clarithromycin 500mg PO / IV BD + Metronidazole 400mg PO / 500mg IV TDS Mild allergy Meropenem 1g TDS Severe allergy Teicoplanin 400mg IV BD for 3 doses then OD + Gentamicin 5mg/kg IV OD∗ Co-amoxiclav NB. Review Mild allergy 1.2g IV TDS Meropenem 1g prescription IV TDS once culture and sensitivity Severe allergy Teicoplanin results available 400mg IV BD for 3 doses then OD + Metronidazole 400mg PO TDS + Ciprofloxacin 500mg – 750mg PO BD Consult Respiratory Team Consult Microbiology/Respiratory Team Refer to separate Once Daily Gentamicin guidelines for prescribing information 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 15 of 22 INFECTIONS 5.17 URINARY TRACT NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Antibiotic Uncomplicated UTI and cystitis Nitrofurantoin 50 -100mg QDS PO (not effective if GFR<60ml/min) Gentamicin 5mg/kg OD IV∗ Pyelonephritis Penicillin Allergy/Alternative Gentamicin 5mg/kg OD IV∗ Comments Consult microbiology Review once results of MSU / blood culture available. If susceptible change to co-amoxiclav. Catheter related infection Gentamicin 5mg/kg OD IV∗ Urinary catheter prophylaxis Epididymitis orchitis See prophylaxis section Ciprofloxacin 500mg PO BD (outpatient) Tazocin® 4.5g IV TDS (inpatient) Prostatitis ∗ Consult microbiology Mild allergy Meropenem 1g IV TDS Severe allergy Ciprofloxacin 500mg PO BD Ciprofloxacin 500mg PO BD Men – 7 days Women – 3 days 14 days treatment required All urinary catheters will become colonised over time. There is no indication for treatment unless the patient is symptomatic. Treat for 10-14 days Must assess patient for risk of sexually transmitted disease – treatment may need to be modified accordingly. Take appropriate swabs and discuss with microbiology. Urology only Refer to separate Once Daily Gentamicin guidelines for prescribing information 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 16 of 22 INFECTIONS 5.18 SKIN AND SOFT TISSUE Always consider previous history of MRSA carriage or of carriage. Add teicoplanin (400mg IV bd for the first three doses then od) to the regimen, and discuss with microbiology. NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Mild infection e.g. Boils, folliculitis Cellulitis Necrotising fasciitis All cases must be discussed with microbiology Urgent surgical referral required Pressure sores Infestations Headlice Infestations Scabies ∗ Category Antibiotic Flucloxacillin 500mg PO QDS Penicillin Allergy Clarithromycin 500mg PO BD Comments Benzylpenicillin 1.2g IV QDS + Flucloxacillin 1g IV QDS Clindamycin 600mg IV QDS Discuss with microbiology if patent ≥65 MRSA Teicoplainin 400mg IV BD for 3 doses then OD + Sodium Fusidate 500mg PO TDS Upper or lower limb Benzylpenicillin 2.4g IV 4o + Clindamycin 1.2g IV QDS Discuss with microbiology Torso Abdomen Scrotum Meropenem 1g IV TDS ± Gentamicin 5mg/kg IV OD∗ Mild allergy Meropenem 1g IV TDS ± Gentamicin 5mg/kg IV OD∗ Severe allergy Discuss with microbiology Uncomplicated: Wound toilet only Complicated: Flucloxacillin 500mg PO QDS + Metronidazole 400mg PO TDS Malathion alcoholic solution/ aqueous liquid Permethrin 5% cream Prolonged IV therapy may be required. Discontinue clindamycin immediately if diarrhoea develops and discuss with microbiology Discontinue clindamycin immediately if diarrhoea develops and discuss with microbiology Phenothrin alcoholic Repeated wet solution/aqueous combing with ‘nit liquid comb’ is most effective treatment Malathion 0.5% Treat all household liquid members Refer to separate Once Daily Gentamicin guidelines for prescribing information 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 17 of 22 INFECTIONS NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Wound infections (post surgical) or venflonitis Animal / human bites Category Antibiotic Flucloxacillin 500mg - 1g PO QDS Prophylaxis Co-amoxiclav 625mg PO TDS for 1 week Treatment of established infection Co-amoxiclav 1.2g IV tds Penicillin Allergy Clarithromycin 500mg PO BD Comments If severe discuss with micro Doxycycline 100mg PO BD + Metronidazole 400mg PO TDS for 1 week Clindamycin 600mg IV qds + Ciprofloxacin 500mg–750mg PO bd Discuss with microbiology if patent ≥65 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 18 of 22 Tetanus vaccine also needed (see BNF for current prescribing details) Consider rabies if bitten abroad Discontinue clindamycin immediately if diarrhoea develops and discuss with microbiology INFECTIONS 5.19 ANTIBACTERIAL PROPHYLAXIS Some key principles to consider 9 Antibiotics should be given when contamination of a wound is expected or when operations on a contaminated site may lead to bacteraemia. The majority of “clean” operations do not warrant prophylaxis. The exception is when prosthetic material is to be implanted where the consequences of infection are grave. 9 Prophylactic regimens should be directed against the most relevant pathogens. It is impossible to cover all organisms. Regimens that decrease the total number of pathogens are usually sufficient. 9 Antibiotics are usually best given parenterally at the time of induction of anaesthesia to ensure effective tissue levels during surgery when there is a maximum risk of local contamination or dissemination. 9 There is no evidence that prolonged prophylaxis has any advantage over single doses. Indeed, prolonged administration tends to lead to the emergence of resistant organisms, superinfection, and is also expensive. 9 Prophylaxis is inappropriate if there is established infection (e.g. where there is established peritonitis due to visceral perforations, or in an infected prosthesis). Full courses of the appropriate antibiotics will be required. 9 Single dose prophylaxis is usually adequate, but in any event, therapy should not exceed 24 hours 9 Additional doses of antibiotics should be given if there is major blood loss of prolonged surgery 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 19 of 22 INFECTIONS 5.19.1 Surgical Prophylaxis NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Surgery Category Antibiotics General Surgery Gynaecological Surgery Vascular Orthopaedic Urology procedures including nephrostomy insertion and manipulations Mesh Hernia Repair No prosthetic device Penicillin Allergy/MRSA Co-amoxiclav 1.2g IV Gentamicin 2mg/kg IV at induction + Metronidazole 500mg IV at induction Co-amoxiclav 1.2g Gentamicin 2mg/kg + IV at induction Clindamycin 600mg IV at induction Co-amoxiclav 1.2g IV Teicoplanin 800mg IV at induction + Gentamicin 2mg/kg IV at induction No prophylaxis required Co-amoxiclav 1.2g IV Gentamicin 2mg/kg IV at induction and for 2 + Teicoplanin 800mg doses post-op IV at induction. Teicoplanin 800mg IV 12 hours post-op Arthroplasty, NOF #, ACL, long bone nailing, instrumentation of joints involving implants (e.g. any ORIF), and any other metal implants Revision of hips/knees Teicoplanin 800mg IV and Gentamicin 2mg/kg IV after tissue sampling, then Teicoplanin 800 mg at 12 and 24 hours and then once daily. Treatment to be reviewed with culture results/histology Gentamicin 2mg/kg IV stat Severe Trauma & Prevention Amputation gangrene of Co-amoxiclav 1.2g IV Gentamicin 2mg/kg IV at induction + Teicoplanin 400mg IV at induction gas Benzylpenicillin 1.2g Discuss with IV QDS + microbiology Metronidazole 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 20 of 22 INFECTIONS 5.19.2 Cardiothoracic Centre Surgical Prophylaxis Procedure Antibiotic choice 1 Antibiotic choice 2 MRSA negative and not allergic to penicillins MRSA positive or unknown or penicillin allergy or recent or past infective endocarditis any weight CABG and Valve sugery Thoracic surgery bodyweight < 65kg bodyweight > 65kg Induction: Flucloxacillin 1g IV + Gentamicin 2mg/kg IV Induction: Vancomycin 1g IV + Gentamicin 2mg/kg Induction: Vancomycin 1.5g IV + Gentamicin 2mg/kg Then: Flucloxacillin 1g IV 6 hourly for four more doses Top-up on starting CPB: Vancomycin 500mg IV Top-up on starting CPB: Vancomycin 750mg IV 12 hours after previous dose: Vancomycin 1g IV 12 hours after previous dose: Vancomycin 1.5g IV Induction: Co-amoxiclav 1.2g IV Induction: Induction: Vancomycin 1g IV + Vancomycin 1.5g IV + Gentamicin 2mg/kg IV Gentamicin 2mg/kg IV Then: Co-amoxiclav 1.2g IV 8 hourly for 2 more doses 12 hours after induction: Vancomycin 1g IV 12 hours after induction: Vancomycin 1.5g IV 5.19.3 Urinary Catheter Prophylaxis Procedure Catheter insertion Catheter manipulation Indicated Obstructive uropathy Patients with prosthetic joints or vascular grafts Manipulation of blocked catheters e.g. bladder washouts Manipulation of blocked catheters e.g. bladder washouts 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 21 of 22 Antibiotic Gentamicin 80mg IV / IM stat Gentamicin 80mg IV / IM stat INFECTIONS 5.19.4 Medical Prophylaxis NB. All doses assume normal renal and hepatic function and are via the oral route unless otherwise specified Infection Haemophilus Influenzae Neisseria meningitidis Splenectomy Antibiotic Rifampicin 600mg OD PO Child over 3 months: 20mg/kg OD PO (max. 600mg daily) Ciprofloxacin: Adults and children over 12 years 500 mg stat Children aged 5–12 years 250 mg stat Children 1 month–4 years 125 mg stat Penicillin V 500mg PO BD 2nd Choice Comments For 4 days Rifampicin PO BD for 2 days: Adults and children over 12 years of age 600 mg Children aged 1–12 years 10 mg/kg Infants (under 12 months of age) 5 mg/kg Suitable doses in children based on average weight for age are: 0–2 months 20 mg (l ml*) 3–11 months 40 mg (2 ml*) 1–2 years 100 mg (5 ml*) 3–4 years 150 mg (7.5 ml*) 5–6 years 200 mg (10 ml*) 7–12 years 300 mg (as capsule/or syrup) Erythromycin 500mg PO Ensure the following BD vaccines are given -Menitorix + Pneumovax 5.19.5 Endocarditis Prophylaxis In March 2008 NICE reviewed the use of antibiotic prophylaxis for preventing endocarditis in patients who are high-risk. They have advised against using antibiotic prophylaxis for the prevention of infective endocarditis If a clinician requires that a patient still receives antibiotic cover for any procedure, it is their responsibility to ensure appropriate cover for the likely infecting organisms is given. Each case should be discussed with microbiology. July 2012 5.6 Allergies: hypersensitivity reaction; severe (immediate) – anaphylaxis and delayed – rash Page 22 of 22
