Download Title Document Type Issue no Issue date Jan 2014

Title
Antimicrobial Guidelines for Hospitals
Document Type
Guideline
Issue no
Clinical Governance Support Team Use
Issue date
Jan 2014
Review date
Jan 2016
Distribution
All prescribers, charge nurses, clinical pharmacists
Prepared by
Anne Duguid
Developed by
NHS Borders Antimicrobial Management Team
Equality & Diversity
Impact Assessed
Approved By
NHS Borders Antimicrobial Management Team
Document
Addition/Amendments
App iv – Surgical Prophylaxis Guidelines –
Apr 14
File Location:
Clin_Pharm_Antimicrobial_Guidelines
Approved Date
30.4.14.
Antimicrobial Guidelines for Hospitals
January 2014
Produced by:
NHS Borders Antimicrobial Management Team
Review date January 2016
You can access the most recent version of the Guidelines on the NHS Borders Intranet
Antimicrobials microsite.
2
CONTENTS
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INTRODUCTION …………………………………………………………….
1.1 Penicillin Allergy …………………………………………………….
1.2 Prudent Antimicrobial Prescribing
…………………………..
1.3 Antimicrobial Categories for Prescribers……………………….
SEPSIS AND BLOOD STREAM INFECTIONS ………..………………...
2.1 Sepsis and Sepsis 6……………….……..………………………….
2.2 Sepsis of Unknown Source……………………………………..…..
2.3 Sepsis in Neutropenic Patients (see Appendix viii)
2.4
Central Catheter Related Blood Stream Infection……………..
2.5 Yeast / Candida Blood Stream Infection Secondary to Long
or Central Intravascular Lines ..…………………………………..
2.6
Blood Stream Infection due to Staphylococcus aureus…..…
BONE AND JOINT INFECTIONS ………………………………………….
3.1
Septic Arthritis / Osteomyelitis ………..…………………………
3.2
Prosthetic Joint Infections ……………..…………………………
CENTRAL NERVOUS SYSTEM INFECTIONS ………………………….
4.1
Bacterial Meningitis (“Notifiable” Disease) ……………………
4.2
Viral Meningitis …….……………………………………………….
4.3
Brain Abscess …………..…………………………………………..
4.4
Herpes Simplex Encephalitis ………………….…………………
CARDIOVASCULAR SYSTEM INFECTIONS ……………………………
5.1
Infective Endocarditis ……………..………………………………
EAR, NOSE & THROAT INFECTIONS ……………………………………
6.1
Dental Abscess ….………………………………………………….
6.2
Otitis Externa ……….……………………………………………….
6.3
Otitis Media or Sinusitis ……..……………………………………
6.4
Tonsillitis / Quinsy …………………….……………………………
GASTROINTESTINAL TRACT INFECTIONS ……………………………
7.1
Intra-Abdominal Sepsis including Bacterial Peritonitis ….….
7.2
Hepatobiliary Sepsis ……..………………………………………..
7.3
Antibiotic Associated Diarrhoea …..…………………………….
7.4
Gastroenteritis / Food Poisoning (“Notifiable” Disease) ……
7.5
Oral Candidiasis …………….……………………………….……..
7.6
Systemic Candidiasis …….………………………………………..
7.7
Helicobacter Eradication ……….…………………………………
7.8
Spontaneous Bacterial Peritonitis……………………………….
URO-GENITAL SYSTEM INFECTIONS …………………………………..
8.1
Pelvic Inflammatory Disease (PID) …….………………………..
8.2
Gonorrhoea and/or contact with Gonorrhoea ….……………..
8.3
Chlamydia …………….……………………………………………..
8.4
Epididymo-orchitis ….……………………………………………..
8.5
Genital Herpes …………….………………………………………..
8.6
Vaginal Candidiasis …………….………………………………….
8.7
Penile Candidiasis ……………………….…………………………
URINARY TRACT INFECTIONS …………………………………………..
9.1
Simple Urinary Tract Infections..…………………………………
9.2
Catheter specimen …………..……………………………………..
9.3
Urinary Tract Infections in Pregnancy ……….…………………
9.4
Complicated Urinary Tract Infections ………………….……….
9.5
Prostatitis ……….……………………………………………………
PAGE
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CONTENTS
10 RESPIRATORY TRACT INFECTIONS……………………………………..
10.1
Acute Exacerbations of Chronic Obstructive Pulmonary….
Disease
10.2
Community Acquired Pneumonia………………………………
10.2.1 Legionella………………………………………………………..….
10.2.2 Pneumonia post influenza ………………………………………
10.3
Hospital Acquired Pneumonia…………………….…………….
10.4
Aspiration Pneumonia……………………………………………
10.5
Ventilator Acquired pneumonia…………………………………
10.6
Tuberculosis ……………………………………………………….
11 SKIN AND SOFT TISSUE INFECTIONS………………………………….
11.1 Cellulitis (not perineum)……………………………………………
11.2 Diabetic Foot…………………………………………………………
11.3 Necrotising Fasciitis / Streptococcal Toxic Shock Syndrome
11.4 Surgical Wound Infection ……………………………………..…..
11.5 Traumatic Wounds / Lacerations…………………………………
11.6 MRSA Skin and Soft Tissue Infections………………………….
11.7 Multiple injuries and/or compound fractures of long bones
11.8 Bites……………………………………………………………….…..
11.9 Herpes…………………………………………………………….…..
11.10 Leg Ulcers / Pressure Sores / PEG sites…………….….….…..
APPENDIX i …………………………………………………………………………
MONITORING ANTIMICROBIAL DOSAGE
Gentamicin ………………………………………………………………………...
Vancomycin ……………………………………………………………………….
APPENDIX ii…………………………………………………………………………
PREGNANCY AND ANTIMICROBIALS
APPENDIX iii………………………………………………………………………..
ANTICOAGULANTS AND ANTIMICROBIALS
APPENDIX iv………………………………………………………………………..
SURGICAL PROPHYLAXIS GUIDELINES
APPENDIX v…………………………………………………………………………
GUIDELINES FOR THE PROTECTION OF THE ASPLENIC
PATIENT
APPENDIX vi………………………………………………………………………..
PROPHYLAXIS OF INFECTIVE ENDOCARDITIS
APPENDIX vii……………………………………………………………………….
GENERAL GUIDANCE FOR IV TO ORAL SWITCH
Appendix viii
PROTOCOL FOR MANAGEMENT OF PATIENTS WITH………………….…
NEUTROPENIC SEPSIS AT BORDERS GENERAL HOSPITAL
APPENDIX ix…………………………………………………………………..……
RENAL IMPAIRMENT AND ANTIBIOTICS
PAGE
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1
INTRODUCTION
This guidance is intended to assist medical staff to make a rational choice of an
antimicrobial before drug sensitivities are known.
It takes into account national and local guidelines and local sensitivities. Reference should
also be made to guidelines for specific areas such as critical care.
Unless otherwise stated, the guidance refers to the treatment of adult patients.
Doses quoted are for patients with normal renal function.
Please feel free to discuss infection problems with the Consultant Microbiologist.
Telephone Numbers:
Consultant Microbiologist ………………………………………………
Microbiology Laboratory ……………………………………………….
Microbiology Secretary …………………………………………………
Advice is also available from Pharmacy:
Antimicrobial pharmacist
Dispensary ………………………………………………………………
Extension 26231
Extension 26250
Extension 26262
Extension 26782
Extension 26609/10
Antimicrobial therapy should be reviewed daily, in the light of:
•
•
•
•
Culture results
Allergy or adverse reaction
None-response
Microbiology consultation
1.1 Penicillin Allergy
The BNF has clear guidance on penicillin hypersensitivity. In this guideline, alternatives to
penicillins are given as appropriate to the clinical scenario. Cephalosporins or other betalactam antibiotics (including piperacillin / tazobactam and meropenem) should NOT be given
to patients with a history of anaphylaxis, angio-oedema, bronchospasm, urticaria or rash
occurring immediately after penicillin administration.
Please speak to a Consultant
Microbiologist in such cases.
NHS Borders Infection Control Manual contains policies related to the management of patient
with infection and infectious disease and the control and prevention of cross infection (found in
all wards / departments or on the NHS Borders intranet).
Other useful websites:
British Society for Antimicrobial Chemotherapy: Treatment of Hospital
Infections……………………………………………………….. http://www.bsac.org.uk/pyxis/
British National Formulary …………………………………… http://www.bnf.org
Health Protection Scotland ………………………………….. http://www.hps.scot.nhs.uk
5
1.2
Prudent Antimicrobial Prescribing
When choosing Antimicrobials consider:
1. Choice
• The likely organisms causing the infection
• Allergies and contra-indications
• Previous antimicrobial therapy
• Antimicrobial likely to achieve adequate concentrations at site of infection?
• Change according to culture and sensitivities
• Site of infection
• Severity.
• Age, weight, renal and hepatic function of the patient
• Consider oral route if appropriate for the patient
• Reassess IV route within 48 hours (see Appendix vii, General Guidance on IV to Oral
Switch Guidelines). Choose oral antibiotic according to guideline or according to
sensitivities.
2. Duration
• According to guidelines. Otherwise keep to 5 days and then review
• Always indicate a stop date or course length in the drug kardex and patient case notes
• Remember antimicrobials must be given regularly, e.g. every 6 hours or 8 hours
When writing prescriptions for Antimicrobials
Please refer to the British National Formulary for general guidance on prescribing and
prescription writing.
British National Formulary ……………………………………….
http://www.bnf.org
6
1.3
ANTIMICROBIAL CATEGORIES FOR PRESCRIBERS
To assist in the management of antimicrobial prescribing, and minimise the emergence
of resistance amongst bacteria, the antimicrobials stocked in Pharmacy are grouped
into three categories.
Group I
Antimicrobial agents, which can be prescribed by all doctors when appropriate:
Amoxicillin
Benzylpencillin
Cefalexin
Cefotaxime (for CNS infections)
Chloramphenical (eye preparations)
Clarithromycin IV
Clarithromycin oral
Doxycycline oral
Flucloxacillin
Fluconazole oral
Gentamicin
* Metronidazole
Nystatin suspension
Phenoxymethylpenicillin
Rifampicin (meningococcal prophylaxis)
Trimethoprim
Group II
Antimicrobial agents that can only be prescribed for specific conditions, or infections as per
antimicrobial guideline, or when indicated by culture and sensitivity results.
Azithromycin (STI only)
Cefixime (STI only)
Ceftazidime –
Ceftriaxone (STI only)
Chlorampenicol
Ciprofloxacin
Clindamycin
*Co-amoxiclav
Co-trimoxazole
Fluconazole IV
Mupirocin nasal ointment
Naseptin
Ofloxacin (STI only)
Rifampicin (TB & Meningococcal Prophylaxis)
Sodium Fusidate oral
*piperacillin/tazobactam
Teicoplanin
Vancomycin
Group III**
Antimicrobials that can only be prescribed on the advice of a Consultant Microbiologist.
Amphotericin IV
Caspofungin
Ceftriaxone (except for STI)
Flucytosine
5FC (Flucytosine)
* Meropenem
Rifampicin
Sodium Fusidate IV
Voriconazole
* Do not prescribe metronidazole with co-amoxiclav (amoxicillin / clavulanic acid), piperacillin/
tazobactam or meropenem
** In extreme circumstances, the critically ill patient may require antimicrobials out of Group III
prior to discussion with the Consultant Microbiologist. The Consultant Microbiologist should
be contacted as soon as possible in such circumstances.
7
2.0 SEPSIS AND BLOOD STREAM INFECTIONS
2.1
SEPSIS AND SEPSIS 6
Sepsis is important: it kills more people than acute myocardial infarction!
Prompt management of sepsis saves lives.
The goal of the Sepsis 6 is to reduce mortality by 25%
What is the Sepsis 6?
A bundle of interventions to be achieved within 1 hour (see below).
What triggers the Sepsis 6?
Any patient with a SIRS score of 2 or more (2 or more yellow boxes) and a suspicion of
infection driving this inflammatory response.
What do you do?
All of the actions below. To make it easier, there is a sticker to document all of it in the notes.
Use this as it helps us to audit the patients with sepsis.
SEPSIS 6
1.
2.
3.
4.
5.
Give high flow oxygen
Take blood cultures (ideally before antibiotics start)
Give iv antibiotics
Start iv fluid resuscitation
Check lactate (needs a yellow tube) and FBC (use
sepsis order set)
6. Monitor hourly urine output.
and refer patient to critical care outreach
Easy. 3 things to check (lactate, blood cultures and urine output) and 3 things to do (give
oxygen, fluids and antibiotics). The blood tests are part of the ‘Sepsis 6’ order set on Trak.
IMPORTANT: the patient has to actually receive the antibiotics to get any benefit from them. If
this means administering them yourself then that is a good use of anybody’s time!
Treatment of Sepsis
There are three key features of the management of the patient with sepsis:
1. Recognition: early recognition is crucial to improvement of mortality from this important
condition. In the BGH the SIRS chart will capture these patients early, and with a
confirmed or suspected source of infection the diagnosis is made.
2. Prompt diagnosis and treatment: Sepsis 6: complete the bundle within 1 hour.
Administration of appropriate IV antibiotics to the septic patient is essential: for
every hour you delay the mortality can increase by 7%.
8
3. Organ support: if required the patient may need organ support in the ITU. Referral of
all patients with sepsis to Critical Care Outreach will make this process easier.
Your goal is to break the chain of progression from infection to sepsis to septic shock
to multiple organ failure to death. With the Sepsis 6 bundle we can do that – and
reduce the chances of patients dying.
Definition
Infection
Mortality
Organisms at a normally sterile site with some
inflammation.
SIRS
Systemic Inflammatory Response Syndrome
Host inflammatory response
May or may not be caused by infection
2 or more of:
▫ Temperature >38oC or < 36oC
▫ Heart Rate >90 beats/min
▫ Respiratory rate >20
▫ White Cell
Count >12,000 cell/mm3 or < 4,000
3
cell/mm
Sepsis
Severe Sepsis
Suspected or confirmed infection plus SIRS
Septic Shock
Sepsis induced hypotension (<80mmmHg or 30% less
than normal) despite adequate fluid resuscitation
Multiple Organ
Failure
Failure of more than two organ systems requiring acute 60-80%
support as a result of sepsis.
Sepsis with dysfunction of one or more organs
▫ Elevated Lactate
▫ Altered mental state
▫ Oliguria
▫ Hypotension
10-15%
20-30%
40-60%
9
2.2
SEPSIS OF UNKNOWN SOURCE
If the source of infection is known, antimicrobial therapy can be based on the most suitable
empirical therapy for the infection, pending results of culture and susceptibility tests.
If source is unknown, take appropriate samples of specific body fluids, e.g. urine, sputum to
determine the source of infection.
Sepsis of unknown source
Initial Treatment
Co-amoxiclav 1.2g IV 8 hourly
plus
Gentamicin extended interval dosing See Appendix i, Monitoring Antimicrobial Dosage
If MRSA suspected add Vancomycin IV (see Appendix i, Monitoring Antimicrobial Dosage)
If intra-abdominal source suspected see Section 7.1.
Penicillin allergy
Vancomycin (see Appendix I, Monitoring Antimicrobial Dosage)
Plus
Ciprofloxacin 400mg IV 12 hourly ( IV for first dose then review if appropriate to switch
patient to oral)
Plus
Metronidazole 500mg IV 8 hourly
Change according to results of sensitivities. Switch to oral as soon as appropriate.
2.3
Sepsis in Neutropenic Patients (see Appendix viii)
Take initial sets of blood culture samples, up to 2 sets advised (one from peripheral site and
one from line, if in-situ). Patients receiving nephrotoxic chemotherapy, e.g carboplatin or
cisplatin should not receive Gentamicin: contact Consultant Microbiologist or Haematologist
for advice.
Initial Treatment
Piperacillin / tazobactam 4.5g IV 6 hourly
plus
Gentamicin extended interval dosing. See Appendix i, Monitoring Antimicrobial Dosage.
Penicillin Allergy See Appendix viii
Modify treatment on result of culture and discuss with Microbiologist and/or
Haematologist if no improvement.
2.4
Central Catheter Related Blood Stream Infection
The priority is prevention of infection from these lines. Adhere rigidly to the care bundles for
these lines. Review the need for the line daily and if not required remove it. The rate of
10
infection from these lines has been significantly reduced by following these rules and very
careful insertion in the first place.
If infection from a central line is suspected (Catheter Related Blood Stream Infection) the
default position should be to remove the line. For tunnelled lines (Hickman lines) this is
difficult, so discuss with a Consultant Haematologist.
The tip of the removed central line should be sent for culture along with peripheral blood
cultures. For removal of central lines, advice and guidelines are available from ITU.
If antibiotics are required
As most line infections are due to coagulase-negative staphylococci, initial therapy should be
directed against these organisms.
Vancomycin seeAppendix i Monitoring Antimicrobial Dosage.
or Teicoplanin 400mg IV 12 hourly for 3 doses then 400mg 24 hourly
Review Daily (Check dose with Microbiologist as in some cases 10mg/kg required).
If sensitivities show methicillin sensitive Staphylococcus aureus change to
Flucloxacillin 1g IV 6 hourly for 14 days total. CSM advice (hepatic disorders) see BNF.
Antibiotics should be reviewed after 48 hours when cultures results are available and if
necessary de-escalated. They may no longer be required after removal of the line, or could be
changed to match the sensitivities of any organisms detected. Clinical judgement and
discussion with Consultant microbiologist is required.
2.5
Yeast / Candida Blood Stream Infection
Secondary to Long or Central Intravascular Lines
Always discuss with Consultant Microbiologist. Early removal or change of line(s) is
fundamental to management.
Initial Treatment
Fluconazole 400mg IV stat, then 200mg to 400mg IV / oral once daily.
2.6
Blood Stream Infection due to Staphylococcus aureus.
Staphylococcus aureus sepsis is a serious condition and can be associated with deep seated
infections and severe sequelae. Any patient with blood cultures positive for Staphylococcus
aurues must be treated with a minimum of 2 weeks IV antibiotic therapy. If investigations show
a deep seated source, longer treatment will be required, please discuss with microbiology.
If Staphylococcus aureus is flucloxacillin sensitive, treat with IV flucloxacillin 1-2 grams 6
hourly.
If flucloxacillin resistant, use vancomycin (See Appendix i Monitoring Antimicrobial Dosage)
11
3
BONE AND JOINT INFECTIONS
3.1
Septic Arthritis / Osteomyelitis (Native joint, not diabetic ulcer associated)
Blood cultures, joint aspirates and other appropriate samples from potential source of infection
MUST be taken prior to therapy.
Discuss with Consultant Microbiologist if risk of Methicillin resistant Staphylococcus aureus or
Staphylococcus epidermidis or if gonococcal septic arthritis is suspected.
All therapy should be modified with culture results.
Initial Treatment
First 2 weeks
Flucloxacillin 1g to 2g IV 6 hourly
CSM advice (hepatic disorders) see BNF
Third week
Flucloxacillin 500mg to 1g IV or oral 6 hourly
onward, if
infection
confirmed
If infection not confirmed discuss with microbiology
Penicillin Allergy
First two Weeks Vancomycin, (see Appendix i, monitoring antimicrobial dosage)
Third week
Doxycycline 200mg daily
onward, if
infection
confirmed
If infection not confirmed discuss with microbiology
If risk factors for gram negative infection (for example UTI, prostate symptoms, recent intraabdominal surgery), add Gentamicin as single daily dosing. See Appendix i, Monitoring
Antimicrobial Dosage
Effectiveness of therapy can be monitored using CRP estimation once or twice each week.
Duration Treatment:
3.2
Septic arthritis: 4 to 6 weeks
Osteomyelitis: up to 6 months
Prosthetic Joint Infections
Establish the microbiology of the infection. If occurring within 6 months of surgery, the
organism is commonly Staphylococcus aureus. If the infection is late onset, it is usually
coagulase-negative staphylococci or Gram-negative bacilli.
Discuss all cases with Consultant Microbiologist as a variety of antibiotic combinations
may be appropriate.
12
4
CENTRAL NERVOUS SYSTEM INFECTIONS
4.1
Bacterial Meningitis (“Notifiable” Disease)
On admission (adults)
Cefotaxime 2g IV 6-8 hourly
change to
Benzylpenicillin 2.4g IV 4 hourly if culture shows meningococcal disease or sensitivities
indicate
In all patients over 55 years or immunocompromised, and in all other cases where Listeria is
suspected, add amoxicillin 2g IV every 4 hours.
Penicillin Allergy
If history of anaphylaxis or bronchospasm with Penicillin, discuss with Consultant
Microbiologist
Chloramphenicol 25mg/kg IV 6 hourly
Duration of Treatment
Meningitis caused by meningococci
Treatment for 5-10 days may suffice
Meningitis caused by pneumococci
Treatment for 10-14 days
Seek advice from Consultant Microbiologist if isolates unusual,
immunocompromised, post neurosurgery or when the aetiology is in doubt.
Chemoprophylaxis of Meningococcal Disease
First choice
Ciprofloxacin for most age groups and in pregnancy (rifampicin if <1 month)
Given on advice of Public Health Doctor, contact through switchboard.
Doses (all oral)
Adults and Children over 12 years
Children aged 5 – 12 years
Children 1 month to 4 years
Children under 1 month
in
the
Ciprofloxacin 500mg as a single dose
Ciprofloxacin 250mg as a single dose
Ciprofloxacin 125mg as a single dose
Rifampicin 5mg/kg every 12 hours for 2 days
The administration of ciprofloxacin may be followed by anaphylactic reactions. Healthcare
staff should give out information sheets that include the risk of side effects and be prepared
to deal with allergic reactions. It can also interact with other drugs but a single dose is
unlikely to have a significant effect. It has an unpredictable effect on epilepsy.
Further information including alternative regimens and information sheets can be found at
www.hpa.org.uk in the section on meningococcal disease.
13
4.2
Viral Meningitis
Antimicrobials not indicated unless Herpes viruses suspected.
Take extra CSF sample for Enterovirus or Herpes Simplex virus (HSV) PCR, as appropriate,
as well as throat swab in viral transport medium.
4.3
Brain Abscess
Usually causative agents are: anaerobes, Streptococcus species or Enterobacteriacae
Cefotaxime 2g IV 6-8 hourly
plus
Metronidazole 500mg IV 8 hourly
4.4
Herpes Simplex Encephalitis
Take CSF sample for HSV PCR
Aciclovir 10mg/kg IV 8 hourly for 10 days
14
5
CARDIOVASCULAR SYSTEM INFECTIONS
5.1
Infective Endocarditis
Discussion of all cases of endocarditis (including culture negative) with a Consultant
Microbiologist and Cardiologist is strongly advised.
Send three sets of blood cultures, from separate sites, over a 24 hour period if possible. In
the acutely ill, two sets should be taken within 1 hour before starting empirical therapy.
Initial Empirical Treatment
Native Valve Endocarditis (NVE) - Indolent presentation
Amoxicillin 2g IV 4 hourly
alone or plus
Gentamicin see divided dosing protocol appendix i Monitoring Antimicrobial Dosage
If genuine penicillin allergy, use regimen for severe sepsis, below.
NVE severe sepsis
In severe sepsis, Staphylococci spp. need to be covered. Patients at increased risk of
staphylococcal endocarditis include iv drug abusers and patients with intravascular devices.
Vancomycin – for dosing regimen see Appendix i Monitoring Antimicrobial Dosage
plus
if eGFR>30 ml/min Gentamicin. See divided dosing protocol Appendix i Monitoring
Antimicrobial Dosage
if eGFR <30 ml/min use ciprofloxacin as alternative
If patients have risk factors for multiresistant Enterobacteriaceae or Pseudomonas, eg.
evidence of previous colonisation, use meropenem 2g 8 hourly in place of gentamicin.
Prosthetic valve endocarditis (PVE)
Vancomycin – for dosing regimen see Appendix i Monitoring Antimicrobial Dosage
plus
Rifampicin oral 300mg to 600mg 12 hourly
plus
if eGFR>30 ml/min Gentamicin. See divided dosing protocol Appendix i Monitoring
Antimicrobial Dosage
If eGFR <30 ml/min use ciprofloxacin as alternative
Once causative organisms are known antibiotics should be tailored to the organisms isolated
following discussion with the Consultant Microbiologist.
Treatment follows the British Society for Antimicrobial Chemotherapy (BSAC) Endocarditis
Working Party recommendations.
Reference:
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 2012, 67, 269-289 http://jac.oxfordjournals.org/content/67/2/269.full.
15
6
EAR, NOSE, MOUTH AND THROAT INFECTIONS
6.1
Dental Abscess
Penicillin V 500 mg oral 6 hourly
(some advocate Amoxicillin 250 mg oral 8 hourly but BEWARE side effects diarrhoea,
candidiasis)
Penicillin allergy
Metronidazole 400 mg oral 8 hourly
6.2
Otitis Externa
Refer to Borders Joint Formulary “Infections” section.
6.3
Otitis Media or Sinusitis
Refer to Borders Joint Formulary “Infections” section.
6.4
Tonsillitis / Quinsy
Refer to Borders Joint Formulary “Infections” section
16
7
Gastrointestinal Tract Infections
7.1
Intra-Abdominal Sepsis including Bacterial Peritonitis
Initial Treatment
Amoxicillin 1g IV 8 hourly
plus
Metronidazole 500mg IV 8 hourly
plus
Gentamicin (Extended Interval Dosing. See Appendix i Monitoring Antimicrobial Dosage)
Penicillin or Cephalosporin allergy
If B-lactam allergy, consider vancomycin plus ciprofloxacin plus metronidazole
and discuss with Microbiologist
7.2
Hepatobiliary Sepsis
Amoxicillin 1g IV 8 hourly
plus
Metronidazole 500mg IV 8 hourly
plus
Gentamicin (Extended Interval Dosing. See Appendix i Monitoring Antimicrobial Dosage
Penicillin or Cephalosporin allergy
If B-lactam allergy, consider vancomycin plus ciprofloxacin plus metronidazole, and discuss
with Microbiologist.
7.3
Antibiotic Associated Diarrhoea
Only 40% of cases are associated with Clostridium difficile toxin production. All are due to
disruption of the normal bowel flora. There is no need to send repeat specimens from patients
with previous positive results unless there is a recurrence after a full course of treatment.
If possible, STOP all antimicrobials. Discuss continuation of therapy with Consultant
Microbiologist. Diarrhoea will begin to settle in 2 to 3 days in the majority of patients.
Consider oral rehydration therapy. Consider treating according to protocol below if
C.difficile toxin found in stool and if diarrhoea is bloody, persists, is severe or patient
has abdominal distension and fever.
17
NHS Borders Treatment of C.difficile-associated disease (CDAD): first and second
episodes
•
Treatment of CDAD should be initiated based on assessment of symptoms and severity of
disease while taking into account individual risk factors of the patient.
Consider treatment if C.difficile toxin found in stool and if diarrhoea is bloody, persists, is
severe or patient has abdominal distension and fever
Antibiotic treatment is not required if patient has C.difficile toxin and non or resolving diarrhoea
•
•
•
•
•
Ensure infection prevention and control measures are in
place as soon as symptoms occur (do not wait for lab result
to confirm diagnosis before putting control measures in
place)
Stop any (non-C.difficile) antimicrobial treatment in patients
with CDAD if possible. Discuss continuation of any therapy
with microbiologist
Stop gastric acid suppressive therapy if possible e.g. PPIs,
H2 antagonists.
Severity markers:
•
•
•
•
•
•
•
•
Temperature >38.5°C
Patient has major risk factors (eg. immunosupression)
Hypotension (systolic bp <90mm/Hg)
Suspicion of pseudomembranous colitis, toxic megacolon, ileus
Colonic dilatation in CT scan >6 cm (CT scan not routinely recommended)
White blood cell count > 15x109cells/l
Creatinine>1.5 x baseline
Albumin <25 g/l
Patient has no severity
markers:
Treat with oral metronidazole
400mg 8 hourly for 10-14 days
Rehydrate patient
Daily assessment of patient with mild to
moderate disease:
Observe bowel movement, symptoms
(WBC&hypotension) and fluid balance
If condition doesn’t improve after 5 days’
treatment with oral metronidazole, patient
should be switched to treatment with oral
vancomycin (125mg 6 hourly for 10-14 days)
Patient has one or more
severity markers:
Treat with oral vancomycin
125mg 6 hourly for 10-14
days
Rehydrate patient
Daily assessment of patient with severe disease:
Observe bowel movement, symptoms
(WBC&hypotension) and fluid balance.
Surgery, gastroenterology and microbiology
consultations.
CT scanning: consider pseudomembranous colitis, toxic
megacolon, ileus or perforation.
Patients with severe CDAD with hypotension or ileus
should receive IV metronidazole 500mg 8 hourly in
addition to oral vancomycin for 10-14 days or as
recommended by Consultant Microbiologist.
If diarrhoea continues, or is a third episode, or in severe disease, discuss further management with
Consultant Microbiologist. Probiotics may be initiated by specialists in patients experiencing a third or
subsequent episode.
18
7.4
Gastroenteritis / Food Poisoning (“Notifiable” Disease)
In general, antimicrobial therapy should be avoided, as most bacterial infections are
self-limiting. Generally antibiotics only reduce diarrhoea by 1-2 days, can cause resistance
and are contraindicated in E. coli 0157 infection where they may enhance toxin release and
increase the risk of haemolytic uraemic syndrome.
If patient is immunocompromised, or has signs/symptoms suggestive of deep seated or
invasive infection, please discuss treatment options with a Microbiologist.
Stool and, where appropriate, blood cultures should be taken and clearly labelled with relevant
history, including travel history.
7.5
Oral Candidiasis
First choice
Fluconazole 50mg to 100mg oral 24 hourly for 7 to 14 days
Second choice
Nystatin suspension 100 000 units per ml, 1ml 6 hourly after food usually for 7 days
(continue for 48 hours after lesions have resolved)
7.6
Systemic Candidiasis
Discuss with Consultant Microbiologist
Fluconazole 400mg oral initially then 200 - 400mg daily
(IV only if oral route not possible)
7.7
Helicobacter Eradication
First line treatment
Omeprazole 20mg 12 hourly for 7 days
Clarithromycin 500mg oral 12 hourly for 7 days
Amoxicillin 1g oral 12 hourly for 7 days
or
Omeprazole 20mg 12 hourly for 7 days
Clarithromycin 250mg oral 12 hourly for 7 days
Metronidazole 400mg oral 12 hourly for 7 days
Second line treatment
See BNF for alternative regimes. Refer patient to specialist if eradication has failed
with ONE of the above regimens.
Any antibiotic used recently should be avoided in the eradication regime.
19
7.8
Spontaneous Bacterial Peritonitis
First line treatment
Co-amoxiclav 1.2g IV 8 hourly
Second line treatment
Cefotaxime 2g IV 8 hourly
Or, in immediate (type 1) beta-lactam sensitivity,
Vancomycin IV (see appendix i: monitoring antimicrobial dosage)
plus
Ciprofloxacin 500mg oral 12 hourly (IV if enteral route unavailable). Consult Microbiologist if
patient has been receiving a quinolone as SBP prophylaxis.
Prophylaxis
Norfloxacin 400mg oral daily
20
8
URO-GENITAL SYSTEM INFECTIONS
It is essential that Sexually Transmitted Infections especially Chlamydia, Gonorrhoea, and
Syphillis are reported to GUM Clinic for follow-up and contact tracing. Also see
www.borderssexualhealth.org
Failure to refer carries a high risk of re-infection.
GUM Health Advisors should be contacted on the following numbers:
GU Clinic, Galashiels Health Centre
01896 663700
8.1
Pelvic Inflammatory Disease (PID)
Treatment follows NHS Borders STI Management Protocol.
Antimicrobial treatment should be commenced as soon as diagnosis is suspected.
Women with suspected PID should be screened for Gonorrhoea and Chlamydia.
Out-Patient or non-severe
Ofloxacin 400mg oral 12 hourly for 14 days
CSM advice (tendon damage) see BNF
plus
Metronidazole 400mg oral 12 hourly for 14 days
Inpatient and severe
Ofloxacin 400mg IV 12 hourly (infused over at least 1 hour)
plus
Metronidazole 500mg IV 8 hourly
Switch to oral to complete course as soon as clinically appropriate.
8.2
Gonorrhoea and/or contact with Gonorrhoea
1st Line: Ceftriaxone 500mg IM single dose
or 2nd Line: Cefixime 400mg oral single dose.
plus
azithromycin 1g as a single dose for possible Chlamydia co-infection
8.3
Chlamydia
Treatment follows NHS Borders STI Management Protocol.
Treatment should be initiated without waiting for laboratory information.
Suitable samples
• In men, a first void urine
• In women, undergoing a vaginal examination, a cervical swab
• In women not undergoing a vaginal examination, a first void urine
• A self-taken swab is an alternative for women not undergoing a vaginal examination
Uncomplicated men and women
Azithromycin 1g oral single dose
or
Doxycycline 200mg oral stat then 100mg 12 hourly for 6 days
21
Pregnant women OR risk of pregnancy
Azithromycin is not licensed for use in pregnancy but is very widely used. (Discuss with GUM)
Caution: Erythromycin and amoxicillin have a recognised failure rate hence careful follow-up
necessary. Ofloxacin and doxycycline are contra-indicated in pregnancy.
Erythromycin 500mg oral 12 hourly for 14 days
or, if intolerant to erythromycin
Amoxicillin 500mg oral 8 hourly for 14 days
Treatment of Neonatal chlamydial eye infection
Erythromycin 12.5mg/kg oral 6 hourly for 14 days
8.4
Epididymo-orchitis
All sexually active men should be tested for Chlamydia prior to treatment
Sexual transmission suspected or men under 35, cause unknown
1st line Doxycycline 100mg oral 12 hourly for 14 days
or
2nd line Erythromycin 500mg oral 12 hourly for 14 days
plus
Ceftriaxone 500mg IM single dose
No suggestion of sexual transmission or men over 35, cause unknown
1st line Ofloxacin 400mg oral 12 hourly for 14 days
or
2nd line Ciprofloxacin 500mg oral 12 hourly for 10 days
CSM advice (tendon damage) see BNF
Review at 14 days. If symptoms persist, for further course of antimicrobial treatment.
8.5
Genital Herpes
First Episode
Aciclovir 200mg oral x 5 times a day for 5 days
or Valaciclovir 500mg oral 12 hourly for 5 days
If symptoms are very severe consider a 10 day course
If frequent recurrences seek advice from GUM (01896 663700)
8.6
Vaginal Candidiasis
Fluconazole 150mg oral single dose (not in pregnancy)
or
Clotrimazole pessary 500mg single dose
If frequent recurrences (defined as four episodes of mycologically proven candidiasis
in 12 months) see NHS Borders STI Management Protocol available on the intranet.
8.7
Penile Candidiasis
Clotrimazole cream 1% 8 hourly for 7 days
22
9 URINARY TRACT INFECTIONS
Reference SIGN 88: http://www.sign.ac.uk/pdf/sign88.pdf
Whenever possible, a specimen of urine should be collected for culture and sensitivity testing
before starting antibacterial therapy. The therapy should reflect current local antibacterial
sensitivity patterns.
In general asymptomatic bacteriuria in the elderly should not be treated with antibiotics. “Dipstick” results are only helpful in MSU.
Remember genital tract sites e.g. vagina, prostate, may give rise to WBC on specimen
microscopy.
Please contact a Nephrologist immediately if a kidney transplant patient is found to have a
urinary tract infection.
9.1
Simple Urinary Tract Infections
Excludes pregnancy and children
Women and Men
First line: Trimethoprim 200mg oral 12 hourly
or
Second line: Nitrofurantoin 50mg oral 6 hourly. Avoid nitrofurantoin in renal failure (eGFR
less than 60ml/min) due to toxicity & lack of efficacy.
Duration of treatment:
Women ……………………………………………………………………….…3 days
Men ………………………………………………………………… …….…...7 days
Further therapy should be based on sensitivity results
9.2
Catheter specimen
In catheterised patients, the bladder quickly becomes colonised. Microscopy and/or “dip-stick”
testing is unhelpful as WBC, rbc, nitrate and protein may all be positive when the bladder is
colonised.
Catheter urine samples should be sent for culture and sensitivities only if patient is febrile or
systemically unwell and bladder is the likely source.
If possible, remove catheter. Treat only if there is clinical suspicion of bacteraemia and, if
appropriate, after consultation with microbiologist. If treating, the catheter should be changed.
Changing of long term urinary catheter:
• Where patients have developed sepsis related to changing a long-term urinary
catheter, prophylaxis may be considered.
• Previously documented antimicrobial resistance should be considered when choosing
an appropriate antimicrobial.
• The following suggestions are made for empirical use in the absence of antimicrobial
resistance information.
23
First choice
GENTAMICIN
Dose: 3 mg/kg (lean body weight) up to a maximum of 320 mg IV single dose
Second choice
TRIMETHOPRIM
Dose: 200mg orally single dose
9.3
Urinary Tract Infections in Pregnancy
Mid-stream urine sample must be taken. Always treat asymptomatic bacteriuria.
A post-treatment specimen should always be sent.
Initial treatment
Cefalexin 250mg oral 6 hourly for 7 days
9.4
Complicated Urinary Tract Infections
Principally pyelonephritis.
Also includes patients with abnormal renal tract, immunocompromised patients, or history of
recurrent UTI's.
Appropriate urine samples should be taken before commencing antimicrobials.
Initial Treatment
Ciprofloxacin 500mg 12 hourly PO
If nil by mouth, use co-amoxiclav IV first line with or without Gentamicin as below.
Second line
Co-amoxiclav 625 mg 8 hourly PO (1.2g 8 hourly IV if pyelonephritis, nil by mouth or
nausea / vomiting - change to PO once able to tolerate)
plus, if severe add Gentamicin (Extended Interval Dosing - see Appendix i Monitoring
Antimicrobial Dosage) to either ciprofloxacin or co-amoxiclav, above
Treat for 7-14 days
Change treatment, according to sensitivities. Switch to oral, according to sensitivities, when
no nausea, vomiting, fever or sepsis.
24
9.5
Prostatitis
Acute Prostatitis requires immediate treatment.
Chronic Prostatitis requires investigation before antimicrobials are started; only 10% of cases
are caused by infection.
Initial treatment
First line
Ciprofloxacin 500mg oral 12 hourly CSM advice (tendon damage) see BNF
Second line
Trimethoprim 200mg oral 12 hourly
Duration of treatment:
Acute and Chronic Bacterial Prostatitis …………………………….…… 4 to 6 weeks
25
10
RESPIRATORY TRACT INFECTIONS
General ref: NICE Respiratory Tract Infectionhttp://www.nice.org.uk/nicemedia/pdf/CG69QRG.pdf.
10.1
Acute Exacerbations of Chronic Obstructive Pulmonary Disease*
Patients with two or more of the three cardinal signs may benefit from treatment with
antimicrobials
•
•
•
Increased shortness of breath
Increased sputum volume
Purulent sputum
Most patients who have persistent purulent sputum between exacerbations are colonised with
Haemophilus, Streptococcus, Staphylococcus, Moraxella or Pseudomonas species.
Antimicrobials should be tailored against previous isolates where possible, otherwise start
treatment with Amoxicillin 500mg oral 8 hourly for 5 to 7 days
Penicillin allergy
Doxycycline 200mg oral on first day then 100mg daily
for a total of 7 days
For treatment failures:
Co-amoxiclav (Amoxicillin/clavulanic acid) 625mg oral 8 hourly for 7 days
If severe
Co-amoxiclav 1.2g IV 8 hourly
Plus
Clarythromycin 500mg IV 12 hourly
(Clarithromycin IV should only rarely be necessary in COPD)
Pseudomonal infections
Ciprofloxacin 750mg oral 12 hourly (use IV route (400mg) only if oral not possible) CSM
advice (tendon damage) see BNF
Note: It is important to distinguish between colonisation/overgrowth and actual infection in
patients with sputum culture positive for Pseudomonas. The patient’s clinical condition should
always be included in the assessment for anti-Pseudomonal antibiotics. Heavy growth of
pure Pseudomonas, repeated positive culture, significant purulence of sputum and presence
of systemic symptoms indicate a greater likelihood of infection as opposed to colonisation /
overgrowth. When colonisation / overgrowth is suspected it is appropriate to delay antibiotics
and continue to review the patient’s clinical progress and/or repeat sputum cultures after an
interval. Resistance to CIPROFLOXACIN is a significant risk in Pseudomonas respiratory
tract infection
*NICE COPD Guideline. http://www.nice.org.uk/nicemedia/pdf/CG012_niceguideline.pdf
Bronchiectasis: See protocol in Borders Joint Formulary
Immunosuppressed Patients: Consult other relevant protocols, e.g. neutropenic sepsis,
HIV.
26
10.2
Community Acquired Pneumonia
CURB-65 Severity Scores for Community Acquired Pneumonia
Any of:
•
Confusion
•
Urea >7 mmol/l
•
Respiratory rate ≥30/min
•
Blood pressure (SBP <90mm Hg or DBP ≤60mm Hg)
•
Age ≥65 years
CURB-65 score
0 or 1
2
GROUP 2
GROUP 1
Mortality low
(1.5%)
Mortality
intermediate
(9.2%)
Consider hospital
supervised treatment
Treatment options
Likely suitable
for home
treatment
Options may include:
(a) short stay inpatient
(b) hospital supervised
outpatient
3 or more
GROUP 3
Mortality high
(22%)
Manage in hospital as severe
pneumonia
Assess for ICU admission
especially if
CURB-65 score = 4 or 5
Antibacterials
Amoxicillin
500mg to 1g oral 8
hourly for 7 days
Penicillin allergy
Clarithromycin
500mg oral 12
hourly for 7 days
Amoxicillin 500mg to 1g orally 8
hourly
plus
Clarithromycin 500mg oral 12
hourly for 7 days
or, if IV required
Amoxicillin 1g IV 8 hourly
plus
Clarithromycin 500mg IV 12 hourly
Switch to oral antibiotics as soon as
clinically appropriate
Penicillin allergy or intolerance to
Clarithromycin
Discuss with Consultant
Microbiologist
Suggest doxycycline
200mg daily
Co-amoxiclav 1.2g 8 hourly IV
plus
Clarithromycin 500mg IV 12
hourly
Alternative in penicillin allergy
Clarithromycin 500mg IV 12
hourly
plus
Vancomycin
See appendix 1
Monitoring Antibiotic Dosage
Switch to oral equivalents as
soon as
Clinically appropriate
(vancomycin switches to
doxycyline)
REMEMBER: Switch from IV oral therapy when clinically stable and by 3 days if RR <25/min,
haemodynamically stable and able to take oral agents.
27
10.2.1 Legionella
Antimicrobial combinations which include clarithromycin will provide cover for Legionella.
Samples for Legionella testing are acute and convalescent sera (clotted blood) and urine for
Legionella antigen.
10.2.2 Pneumonia post influenza
Ref. Thorax, 2007; 62: supp 1.
Hospital treated, non-severe pneumonia, post influenza
Co-amoxiclav 625mg oral tds
or, if IV needed, co-amoxiclav 1.2g tds IV
Penicillin allergy: clarithromycin 500mg oral bd
or, if IV needed, clarithromycin 500mg bd IV
Hospital treated, severe pneumonia, post influenza
Co-amoxiclav 1.2g IV tds
Plus clarithromycin 500mg IV bd
Penicillin allergy: consult microbiologist
10.3
Hospital Acquired Pneumonia
Obtain advice at an early stage.
Contact a Consultant Microbiologist if Pseudomonas or MRSA present or if previously treated
with antimicrobials
Initial treatment
Co-amoxiclav (Amoxicillin / clavulanic acid) 625mg oral 8 hourly
If severe
Co-amoxiclav 1.2g IV 8 hourly
plus
Gentamicin (Extended Interval Dosing See Appendix i Monitoring Antimicrobial Dosage)
Penicillin allergy
Vancomycin (see appendix i monitoring antimicrobial dosage)
plus
Ciprofloxacin 500mg oral 12 hourly
10.4 Aspiration Pneumonia
Co-amoxiclav (Amoxicillin / clavulanic acid) 1.2g IV 8 hourly
Penicillin allergy
Discuss with microbiologist
10.5
Ventilator Acquired pneumonia
Consult ITU protocol
10.6
Tuberculosis
ALL cases of suspected Tuberculosis or other Mycobacterial disease must be referred to the
Respiratory Physician responsible for TB care.
28
11
SKIN AND SOFT TISSUE INFECTIONS
11.1
Cellulitis (not perineum)
Commonly caused by Streptococci, may occasionally involve Staphylococcus aureus.
Non-severe
Flucloxacillin 500mg oral 6 hourly CSM advice (hepatic disorders) see BNF
alone, or plus
Penicillin V 500mg oral 6 hourly
Penicillin allergy
Clarithromycin 500mg oral 12 hourly
Severe
Benzylpenicillin 1.2g IV 4 – 6 hourly
Plus
Flucloxacillin 1g to 2g IV 6 hourly CSM advice (hepatic disorders) see BNF
and consider:
Gentamicin (Extended Interval Dosing. See Appendix i Monitoring Antimicrobial Dosage)
Penicillin allergy – substitute Benzylpenicillin plus Flucloxacillin with:
Vancomycin See Appendix i Monitoring Antimicrobial Dosage
If severe unresponsive cellulitis, consider deeper infections, including necrotising
fasciitis. If this is suspected please discuss with both surgery and microbiology
urgently.
If cellulitis is associated with lymphoedema, refer to NHS Borders Guideline
http://intranet/resource.asp?uid=19446
Orbital Cellulitis
Co-amoxiclav (Amoxicillin / clavulanic acid) 1.2g IV 8 hourly
Penicillin allergy
Cefuroxime 750mg to 1.5g IV 8 hourly
plus
Metronidazole 500mg IV 8 hourly
Skin and soft tissue infections related to drug misuse
Benzylpenicillin 1.2g IV 4 – 6 hourly
Plus
Flucloxacillin 1g to 2g IV 6 hourly CSM advice (hepatic disorders) see BNF
Seek advice from Microbiology
11.2
Diabetic foot
See diabetes protocol on hospital intranet
29
11.3
Necrotising Fasciitis / Streptococcal Toxic Shock Syndrome
Discuss with Consultant Microbiologist
Initial treatment (and for upper limb)
Benzylpenicillin 1.2g to 2.4g IV 4 hourly
plus
Flucloxacillin 1-2g IV 6 hourly
plus
Clindamycin 600mg IV 6 hourly
Initial treatment for lower limb
Tazocin 4.5g IV 8 hourly
plus
Clindamycin 600mg IV 6 hourly
11.4
Surgical Wound Infection
Wounds quickly become colonised, treat and swab only when there are clinical signs of
infection.
Initial treatment
Flucloxacillin 500mg oral 6 hourly for 5 to 7 days
CSM advice (hepatic disorders) see BNF
Penicillin allergy
Clarithromycin 500mg oral 12 hourly for 5 to 7 days
11.5
Traumatic Wounds / Lacerations
Wound infection occurs in 1 – 12% of all non-bite wounds. Antibiotic prophylaxis or tetanus
immunoglobulin is not usually required for simple, clean lacerations.
For high risk tetanus prone wounds (heavily contaminated with soil / faeces or devitalised
tissue) human tetanus immunoglobulin should be given, irrespective of the tetanus
immunisation history of the patient.
A tetanus containing vaccine is given if necessary, according to immunisation history.
Ref: Green Book, Tetanus (chapter 30)
http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/DH_4097254
Treatment of clean lacerations that become infected
Flucloxacillin 500mg oral 6 hourly for 5 to 7 days
CSM advice (hepatic disorders) see BNF
Penicillin allergy
Clarithromycin 500mg oral 12 hourly for 5 to 7 days
Consider antimicrobial prophylaxis if patient is immunocompromised e.g. diabetic, asplenic,
alcohol dependant or laceration is stellate, intra-oral or to the feet. Antibiotics are as for
treatment.
30
Treatment of infected lacerations that were previously contaminated; puncture wounds
or wounds with a significant amount of devitalised tissue
Co-amoxiclav (Amoxicillin / Clavulanic acid) 375 – 625mg oral 8 hourly
Penicillin allergy
Clarithromycin 500mg oral 12 hourly
plus
Metronidazole 400mg oral 8 hourly for 5 to 7 days
Consider antimicrobial prophylaxis in puncture wounds or wounds contaminated with soil,
manure or faeces and wounds with a significant amount of devitalised tissue. Antibiotics are
as for treatment.
11.6
MRSA Skin and Soft Tissue Infections
Cellulitis / febrile but not unstable:
First line
Doxycycline 100mg oral 12 hourly on Day 1, then 100 mg oral 24 hourly
plus
Rifampicin 600mg oral 24 hourly
or
Second line
Trimethoprim 200mg oral 12 hourly
plus
Sodium Fusidate 500mg oral 8 hourly
For all MRSA infections, antibiotic monotherapy should not be given as this can cause rapid
development of resistance.
The only two exceptions to this are Vancomycin and Doxycycline, which in some
circumstances may be prescribed as monotherapy.
Toxic / unstable
Vancomycin For dosing regimen see Appendix i Monitoring Antimicrobial Dosage
11.7
Multiple injuries and/or compound fractures of long bones
Co-amoxiclav 1.2g IV 8 hourly
Penicillin allergy
Discuss with Consultant Microbiologist
REMEMBER
Tetanus prophylaxis
31
11.8
Bites
Consider antimicrobial prophylaxis for the following: human bites, bites to the hand, foot or
face, deep/puncture wounds, wounds requiring surgical debridement, bites to high risk
patients e.g. diabetics, immunocompromised, prosthetic valve. The choice of antimicrobial for
prophylaxis is the same as used for treatment.
See Traumatic Wounds / Lacerations above for management of high risk tetanus prone
wounds.
Human, Dog or Cat bites
Co-amoxiclav (Amoxicillin / clavulanic acid) 625mg oral 8 hourly for 5 days
Penicillin allergy, excluding pregnancy and children
Doxycycline 100mg every 12hours
plus
Metronidazole 400mg oral 8 hourly for 7 days
Penicillin allergy in Pregnancy
Erythromycin 500mg every 12 hours
plus
Metronidazole 400mg oral 8 hourly for 7 days
Consult Microbiologist if animal species is other than a dog or a cat
11.9
Herpes
Herpes Simplex (cold sores)
Aciclovir cream 5% applied 5 times daily at onset of episode for 5 – 10 days
Herpes zoster (shingles)
Treatment beneficial if commenced within 72 hours of onset of rash
Aciclovir 800mg oral fives times daily (every four hours) for 7 days
Disseminated Herpes Infection
Discuss with Consultant Microbiologist
Aciclovir 5mg/kg IV 8 hourly
11.10 Leg Ulcers / Pressure Sores / PEG sites
Antimicrobial treatment is ONLY indicated if there is evidence of spreading cellulitis.
Discuss with Consultant Microbiologist
32
Appendix i
Monitoring Antimicrobial Dosage
Gentamicin Extended Interval Dosing for Adults
Intravenous Gentamicin Use in Adults (GGC Guidance Approved SAPG January 2013)
Background
This policy covers the use of intravenous (IV) gentamicin in adults using the Greater Glasgow
and Clyde (GGC) dosing guidance.
The policy is for the use of gentamicin for the treatment of infection only. SAPG
recommendations on gentamicin dosing for surgical prophylaxis are provided elsewhere.
The guidance does not apply to gentamicin use in the following:
o synergistic treatment of endocarditis or Staphylococcal bone infection
o patients treated in Renal units or receiving haemodialysis or haemofiltration
o major burns
o ascites
o age < 16 years
o cystic fibrosis (refer to local guidelines)
o pregnancy (refer to local guidelines)
Contra-indications and cautions

Contra-indications to gentamicin therapy – hypersensitivity, myasthenia gravis

Cautions to gentamicin therapy:
o
Patients with decompensated liver disease - aminoglycosides are associated with an
increased risk of renal failure.
o
Concurrent administration of neurotoxic and / or nephrotoxic agents increases the risk
of gentamicin toxicity. Review therapy and consider amending or withholding
nephrotoxic drugs during gentamicin treatment. Avoid co-administration with the
following:
• neuromuscular blockers
• other potentially nephrotoxic (e.g. NSAIDs and ACE Inhibitors) or
ototoxic drugs
• potent diuretics
• other aminoglycosides
This list is not exhaustive – consult the Summary of Product Characteristics (eSPC)
for a full list (www.medicines.org.uk)
o
Chronic Kidney Disease (CKD) Stage 4 or more, known or suspected acute kidney
injury in the previous 48 hours (≥ 50% increase in baseline serum creatinine or oliguria
> 6 hours). If gentamicin is clinically indicated, give one dose as per guidance and
check with microbiology or an infection specialist before giving a second dose.
Prescribing and documentation


To improve the prescribing of gentamicin, ensure consistency and reduce risk,
standardised charts (agreed nationally) should be used to document the prescription,
administration and monitoring of gentamicin. These should be used for prescribing
treatment doses of gentamicin in conjunction with the existing inpatient prescribing chart
(e.g. kardex) and medical / nursing documentation.
These charts contain a step-wise approach to safe and effective prescribing and key
points of advice on monitoring, interpreting and re-prescribing.
33
STEP 1:
Calculate, prescribe and administer the first dose

To reduce the risk of mortality, commence gentamicin administration within 1 hour of
recognising sepsis.

If creatinine is known – use the online calculator (preferred method). The guidelines in
Table 1 (below) can be used if the online calculator is not available. The dose amount and
dosage interval are based on estimated creatinine clearance (Box 1) and actual body
weight.

If creatinine is not known – give an initial dose of 5 mg/kg gentamicin (maximum 400 mg)
or, if Chronic Kidney Disease (CKD) 5, give 2.5 mg/kg (maximum 180 mg) on advice of
senior staff. Calculate the dose using actual body weight.

Give the recommended dose by infusion in 100 mL sodium chloride 0.9% over 30 minutes
and ensure the time of administration is noted on the medicine chart.
Box 1: Estimation of creatinine clearance (CrCl)
The following ‘Cockcroft Gault’ equation can be used to estimate creatinine clearance
(CrCl)
[140 – age (years)] x weight (kg) x 1.23 (male) OR x 1.04 (female)
CrCl = ---------------------------------------------------------------------------------------(mL/min)
serum creatinine (micromol/L)
Cautions:
• Use actual body weight or maximum body weight whichever is lower.
For maximum body weight table see
http://www.scottishmedicines.org.uk/files/sapg/Maximum_body_weight_table.pdf
• In patients with low creatinine (< 60 micromol/L), use 60 micromol/L.
• Note: Use of estimated glomerular filtration rate (eGFR) is not recommended.
Table 1: Initial GENTAMICIN doses and dose intervals
Actual body
weight →
40 - 49 kg
50 - 59 kg
60 - 69 kg
70 - 80 kg
Creat Cl
(mL/min) ↓
< 21
> 80 kg
2.5 mg/kg (max 180 mg) then take a sample after 24 hours
21 - 30
180 mg
48 hourly
200 mg
48 hourly
240 mg
48 hourly
240 mg
48 hourly
260 mg
48 hourly
31 - 40
200 mg
48 hourly
240 mg
48 hourly
280 mg
48 hourly
300 mg
48 hourly
320 mg
48 hourly
41 - 50
240 mg
48 hourly
280 mg
48 hourly
320 mg
48 hourly
360 mg
48 hourly
400 mg
48 hourly
51 - 60
200 mg
24 hourly
240 mg
24 hourly
280 mg
24 hourly
300 mg
24 hourly
320 mg
24 hourly
> 60
240 mg
24 hourly
280 mg
24 hourly
320 mg
24 hourly
360 mg
24 hourly
400 mg
24 hourly
Caution: If the patient weighs < 40 kg and CrCl is ≥ 21 mL/min, give a single dose of 5 mg/kg
then take a sample 6 – 14 hours after the dose and follow the instructions in Step 2.
34
STEP 2:
Monitor creatinine and gentamicin concentrations and reassess
the dosage regimen
Concentrations are meaningless unless the dose & sample times are recorded accurately
If creatinine clearance is ≥ 21 mL/min
 Take a blood sample 6-14 hours after the start of the first gentamicin infusion.
 Record the exact time of all gentamicin samples on the gentamicin prescribing chart AND
on the sample request form.
 Record the serum concentration on the gentamicin prescribing chart.
 Plot the concentration measurement on the graph and reassess the dose / dosing interval as
indicated.
 This will indicate one of 3 options: 1) continue the present dosage regimen
2) adjust the dosage interval
3) withhold and resample after 24 hours
If creatinine clearance is < 21 mL/min
 Take a blood sample 24 hours after the start of the first gentamicin infusion.
 Record the exact time of all gentamicin samples using the gentamicin prescribing chart
AND on the sample request form.
 If therapy is to continue, take additional blood samples at least every 24 hours and give a
further dose once the measured concentration is < 1 mg/L.
35
STEP 2:
Monitor creatinine and gentamicin concentrations and reassess
the dosage regimen
General points
 Document the action taken in the medical notes and on the gentamicin prescribing chart.
 Undertake pre-prescribing checks (Boxes 2 and 3) to assess the risk of renal toxicity and
ototoxicity.
 Prescribe the next dose as appropriate.
 Seek advice from pharmacy or microbiology if you are unsure how to interpret the result or if
the concentrations are very low. Doses up to 600 mg may be required for some patients.
 If a blood sample is not taken, is lost or is taken at wrong time and if there is any concern
about the patient’s renal function, take a sample 20-24 hours after the start of the
gentamicin infusion and wait for the result before giving the next dose. Otherwise, take a
blood sample after the next dose.
If the measured concentration is unexpectedly HIGH or LOW, consider the following:
 Were dose and sample times recorded accurately?
 Was the correct dose administered?
 Was the sample taken from the line used to administer the drug?
 Was the sample taken during drug administration?
 Has renal function declined or improved?
 Does the patient have oedema or ascites?
If in doubt, take another sample before re-prescribing and/or contact pharmacy for advice
STEP 3: Assess daily the ongoing need for gentamicin and signs of toxicity
 Take a further blood sample 6-14 hours after the dose, at least every 2 days.
 If the gentamicin concentration is unexpectedly high or if renal function alters, daily
sampling may be necessary.
 To minimise the risk of toxicity, duration of treatment should normally be limited to 72 hours.
All gentamicin prescriptions that continue beyond 3-4 days of treatment must be discussed
with microbiology or an infection specialist. Consider changing to an oral alternative - refer
to the IV to Oral switch policy.
Box 2: Renal toxicity



Monitor creatinine daily. Seek advice if renal function unstable (e.g. change in creatinine of >
15-20%).
Signs of renal toxicity include increase in creatinine or decrease in urine output/oliguria.
Consider an alternative agent if creatinine is rising or the patient becomes oliguric.
Box 3: Ototoxicity
 Ototoxicity secondary to gentamicin is independent of drug concentration. It is suggested by
any of the following: new tinnitus, dizziness, poor balance, hearing loss or oscillating vision.
 Toxicity is associated with prolonged aminoglycoside use (usually > 10 days but may be > 72
hours) and is secondary to drug accumulation within the inner ear.
 Stop treatment if ototoxicity is suspected and refer to microbiology or an infection specialist for
advice on future therapy.
 If gentamicin continues for > 7 days, consider referring to audiology for assessment.
36
Gentamicin Divided Dosing for Adults
Indication
Divided dose Gentamicin is used in endocarditis and some Gram-positive infections on the
recommendation of the Consultant Microbiologist.
Cautions
Monitor renal, auditory and vestibular function in addition to Gentamicin levels. Caution in
patients receiving other nephrotoxic drugs eg. frusemide.
Gentamicin should be avoided completely in myasthenia gravis.
Adult Dose 1mg/kg by intravenous infusion over 30 minutes in 50-100ml Sodium
Chloride 0.9% or glucose 5%
(use actual body weight to calculate gentamicin dose unless patient is obese [BMI ≥30
kg/m2 ] in which case ideal body weight should be used).
Frequency: Dependent on renal function
eGFR>40 ml/min
12 hourly
eGFR 30-40 ml/min
24 hourly
eGFR <30 ml/min
Give first dose then take trough sample after 24h
and await results before redosing
Once causative organisms are known
Dose of Gentamicin and choice of antimicrobial should be tailored to the organisms
isolated; following discussion with the Consultant Microbiologist.
Monitoring Gentamicin Levels
Monitor renal, auditory and vestibular function in addition to Gentamicin levels.
Levels are usually taken around the third dose. Paired blood samples are required.
The first sample or trough sample is taken immediately before the dose.
The second sample or peak sample is taken 60 minutes after the completion of the infusion,
from a different site.
Document the exact time the dose is given and the times the samples are taken.
Type of Infection
Peak Level
Trough Level
Streptococcal endocarditis
3 to 5mg/litre
Less than 1mg/litre
Staphylococcal infection
5 to 8mg/litre
Less than 2mg/litre
Acceptable levels are as above.
If levels are within range and renal function stable repeat levels twice weekly. Monitor
daily if poor or changing renal function.
If levels are out of range Contact Microbiology or Pharmacy for advice on dose adjustment
37
Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion
Background
This policy covers the use of intravenous vancomycin prescribed as an intermittent (pulsed)
infusion. This can be used for treatment or prophylaxis.
This policy does not apply to the use of vancomycin in patients treated in Renal units or
receiving haemodialysis or haemofiltration.
Contra-indications and cautions

Contra-indications to vancomycin therapy – hypersensitivity

Cautions for vancomycin therapy:
o
To avoid the risk of “red-neck/red-man syndrome”, pain or muscle spasm, ensure
that the administration rate is not faster than 500 mg per hour.
o
Concurrent administration of neurotoxic and / or nephrotoxic agents increases the
risk of vancomycin toxicity. Review therapy and consider amending or withholding
nephrotoxic drugs during treatment with vancomycin. Where possible, avoid coadministration with the following:
o
o
o
o
o
amphotericin
potent diuretics
aminoglycosides
NSAIDs
ACE inhibitors
o
The above list is not exhaustive – consult the Summary of Product Characteristics
eSPC for a full list (www.medicines.org.uk).
o
Due to potential ototoxicity, vancomycin should be avoided in patients with
previous hearing loss.
Prescribing and documentation

To ensure consistency, reduce risk and improve the prescribing of vancomycin,
standardised charts should be used where available to document the prescription,
administration and monitoring of intermittent vancomycin infusions. These should be used
in conjunction with the existing inpatient prescribing chart (e.g. kardex) and medical /
nursing documentation.

These charts contain a step-wise approach to safe and effective prescribing and key
points of advice on monitoring, interpreting and re-prescribing.
38
Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion
STEP 1:
Prescribe the loading dose and maintenance dosage regimen

To reduce the risk of mortality, commence vancomycin administration within 1 hour of
recognising sepsis.

If creatinine is known – use the online calculator (preferred method). The guidelines
(below) in Table 1 (loading dose) and Table 2 (maintenance dose) can be used if the
online calculator is not available. The dose amount and dosage interval are based on
estimated creatinine clearance (Box 1) and actual body weight.

If creatinine is not known – calculate and prescribe a loading dose based on actual body
weight (Table 1). Calculate the maintenance dose once the creatinine is available.
Box 1: Estimation of creatinine clearance (CrCl)
The following ‘Cockcroft Gault’ equation can be used to estimate creatinine clearance
(CrCl)
[140 – age (years)] x weight (kg) x 1.23 (male) OR x 1.04 (female)
CrCl = -------------------------------------------------------------(mL/min)
serum creatinine (micromol/L)
Cautions
•
Use actual body weight or maximum body weight whichever is lower.
For maximum body weight table see
http://www.scottishmedicines.org.uk/files/sapg/Maximum_body_weight_table.pdf
•
In patients with low creatinine (< 60 micromol/L), use 60 micromol/L.
•
Note: Use of estimated glomerular filtration rate (eGFR) is not recommended
LOADING DOSE
Table 1: Initial vancomycin LOADING dose
Actual body
weight
Dose
Volume of
sodium chloride
(0.9%)*
Duration of
infusion
< 40 kg
750 mg
250 mL
90 minutes
40 – 59 kg
1000 mg
250 mL
2 hours
60 – 90 kg
1500 mg
500 mL
3 hours
> 90 kg
2000 mg
500 mL
4 hours
* Glucose 5% may be used in patients with sodium restriction.
39
Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion
STEP 1:
Prescribe the loading dose and maintenance dosage regimen
MAINTENANCE DOSAGE REGIMEN

Give the first maintenance infusion 12, 24 or 48 hours after the loading infusion according
to dose interval provided by the online calculator or Table 2 (below).
Table 2: Vancomycin MAINTENANCE dosage regimen
VANCOMYCIN PULSED INFUSION - INITIAL MAINTENANCE DOSAGE GUIDELINES
CrCl (mL/min)
Dose amount
Volume of sodium
chloride (0.9%)*
Dose Interval
< 20
500 mg over 1 hour
250 mL
48 hours
20 - 29
500 mg over 1 hour
250 mL
24 hours
30 - 39
750 mg over 1.5 hours
250 mL
24 hours
40 - 54
500 mg over 1 hour
250 mL
12 hours
55 - 74
750 mg over 1.5 hours
250 mL
12 hours
75 - 89
1000 mg over 2 hours
250 mL
12 hours
90 - 110
1250 mg over 2.5 hours
250 mL
12 hours
>110
1500 mg over 3 hours
500 mL
12 hours
* Glucose 5% may be used in patients with sodium restriction. Doses up to 2000 mg can be
diluted in 500 mL fluid.

The daily dose can be split into 3 equal doses and given 8 hourly. This approach is
especially useful for patients who require high doses as it produces higher trough
concentrations.
For example, 1500 mg 12 hourly (3000 mg per day) could be prescribed as 1000 mg 8
hourly and
750 mg 12 hourly (1500 mg per day) as 500 mg 8 hourly.
STEP 2:
regimen
Monitor the vancomycin concentration and reassess the dosage
Concentrations are meaningless unless the dose & sample times are recorded accurately

Due to wide variability in the handling of vancomycin, early analysis of a vancomycin
concentration is required to ensure that the dosage regimen is appropriate.

Take a trough sample (pre-dose) within 48 hours of starting therapy then every
2 - 3 days, or daily if the patient has unstable renal function.

Monitor creatinine daily.

Record the exact time of all vancomycin samples on the vancomycin prescribing chart
AND on the sample request form.

If renal function is stable, give the next dose before the trough result is available. If renal
function is deteriorating, withhold until the result is available then follow the advice in Table
3.
40
Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion
STEP 2:
regimen
Monitor the vancomycin concentration and reassess the dosage
Target vancomycin concentrations

Target trough concentration range:

If the patient is seriously ill (severe or deep-seated infections), the target range is
15 – 20 mg/L. If the measured concentration is < 15 mg/L, consider increasing the dose
amount or reducing the dosage interval (see 8 hourly dosing above).

If the patient is failing to respond, seek advice from microbiology or an infection specialist.
10 – 20 mg/L
Adjustment of the vancomycin dosage regimen

Always check that the dosage history and sampling time are appropriate before
interpreting the result.

Seek advice from pharmacy or microbiology if you need help to interpret the result.
If the measured concentration is unexpectedly HIGH or LOW, consider the following:






Were the dose and sample times recorded accurately?
Was the correct dose administered?
Was the sample taken from the line used to administer the drug?
Was the sample taken during drug administration?
Has renal function declined or improved?
Does the patient have oedema or ascites?
Table 3: Adjustment of Vancomycin Dosage Regimen
Vancomycin concentration
<10 mg/L
Suggested dose change
Increase the dose by 50% and consider reducing the
dosage interval or seek advice
If the patient is responding, maintain the present
dosage regimen.
10 – 15 mg/L
If the patient is seriously ill, consider increasing the
dose amount or reducing the dosage interval to
achieve a trough level of 15 – 20 mg/L.
15 – 20 mg/L
Maintain the present dosage regimen
>20 mg/L
Stop until <20 mg/L then seek advice
If in doubt, take another sample before modifying the dosage regimen and / or contact pharmacy
for advice
41
Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion
STEP 2:
Monitor the vancomycin concentration and reassess the dosage
regimen
General points
 Record the exact times of all measured concentrations on the vancomycin prescription
chart.
 Undertake pre-prescribing checks (Box 2) to assess the risk of toxicity
 Reassess the dose and continue or prescribe a dosage change
 Document the action taken in the medical notes
 Review the need for vancomycin daily.
Box 2: Toxicity




Monitor creatinine daily. Seek advice if renal function is unstable (e.g. a change in
creatinine of > 15-20%)
Signs of renal toxicity include increase in creatinine or decrease in urine output /
oliguria
Consider an alternative agent if creatinine is rising or the patient becomes oliguric.
Vancomycin may increase the risk of aminoglycoside induced ototoxicity – use
caution if co-prescribing.
42
APPENDIX ii
PREGNANCY AND ANTIMICROBIALS
When considering treatment with an antimicrobial agent during pregnancy, the following
factors should be considered:
•
•
•
•
The severity of the maternal infection
The effects of any fever present on the pregnancy
The consequences or failing to treat the mother
The potential fetotoxicity of the drugs to be used
Where possible, the results of culture and sensitivity tests should be available before making a
treatment choice.
If infections are treated empirically then penicillins and cephalosporins are the agents of
choice.
For further advice or information contact Consultant Microbiologist and Pharmacy and refer to
BNF.
Antimicrobial (systemic)
Penicillins
e.g. Amoxicillin
Erythromycin
Tetracyclines
Aminoglycosides
e.g. Gentamicin
Cephalosporins
Trimethoprim
Nitrofurantoin
Quinolones
e.g. Ciprofloxacin
and Nalidixic Acid
Metronidazole
Aciclovir
Effect (trimester of administration)
Not known to be harmful
Not known to be harmful
Maternal liver failure (2, 3)
Adverse effects on fetal teeth and bones (1,2,3)
Not teratogenic. However, potential for nephro-and ototoxicity
(2, 3)
Avoid unless essential
Careful monitoring of levels in mother essential
Not known to be harmful
Avoid – teratogenic risk (folate antagonist) (1)
Neonatal haemolysis (3)
Avoid-theoretical risk of Arthropathy (1, 2, 3)
Seek advice from a Consultant Microbiologist
Avoid high dose regimes (over 1.5g daily)
Not known to be harmful
Manufacturer advises to use only if benefits outweigh risks
Treatment of choice, when indicated, in preference to other
anti-virals
43
APPENDIX iii
ANTICOAGULANTS AND ANTIMICROBIALS
The following antimicrobials are known to interact with oral anticoagulants.
Advice should be sought from a Consultant Haematologist or Pharmacist preferably before, or
within 24 hours of, prescribing.
Anticoagulant effect may be REDUCED by
•
Rifampicin
Anticoagulant effect may be ENHANCED by
•
•
•
•
•
•
•
•
Ciprofloxacin/Ofloxacin
Fluconazole/Itraconazole
Erythromycin/Clarithromycin
Metronidazole
Sulphonamides
Nalidixic Acid
Tetracyclines
Trimethoprim
Refer to BNF for further information.
If a patient on oral anticoagulants requires antimicrobial therapy, problems are least likely to
be encountered with the penicillins or the first and second-generation cephalosporins such as
Cefalexin or Cefuroxime.
However, clinical experience indicates that oral broad-spectrum agents such as amoxicillin
may alter the INR, possibly through an effect on the gut bacterial flora.
Other factors such as diet and level of physical activity can also affect a patient’s response to
oral anticoagulants. Close monitoring is advised during periods of illness.
In general, when prescribing an antimicrobial:
Keep the course length to a minimum.
If the course is to be longer than five days, therapy should be discussed with a Consultant
Microbiologist or Consultant Haematologist.
The INR should be checked on day 2 of antimicrobial therapy and advice taken as to whether
further checks are required.
44
APPENDIX iv
SURGICAL PROPHYLAXIS GUIDELINES
The goals of prophylaxis administration of antimicrobials to surgical patients are to:
• Reduce the incidence of surgical site infection
• Use antimicrobials in a manner that is supported by evidence of effectiveness
• Minimise the effects of the antimicrobials on the patient’s normal gut flora
• Minimise adverse effects
• Cause minimum changes to the patient’s host defences
All IV doses should be given within 60 minutes prior to skin incision and as close to time of
incision as practically possible.
Doses are usually intravenous and generally the same as those used therapeutically.
Single doses only to be prescribed unless otherwise stated.
Further doses are only required in prolonged procedures (>4h) or if there is significant blood
loss (>1500ml in adults and 25ml/kg in children).
Contaminated or dirty, infected wounds require treatment courses not prophylaxis
Pregnant patients: Gentamicin should be avoided in pregnancy. Cefuroxime is suitable
alternative.
General Surgery
Appendectomy
Gentamicin 3mg/kg IV (maximum 320mg)
plus Metronidazole 500mg IV
Colorectal surgery
Gentamicin 3mg/kg IV (maximum 320mg)
plus Metronidazole 500mg IV
Upper GI Surgery e.g. cholecystectomy
*(Not recommended for laparoscopic Gentamicin 3mg/kg IV (maximum 320mg)
procedure unless ‘High Risk’ see below)
Endoscopic retrograde
Cholangiopancreatography (ERCP)
**(Recommended for ‘High Risk’ patients
only see below)
Mastectomy/wide local excision/ axillary
node sampling/breast
biopsy/microdochectomy/tissue expander
prosthesis
Hernia repair with or without mesh
Gentamicin 160mg IV
Haemorrhoidectomy, including stapled
haemorrhoidopexy
PEG insertion
Gentamicin 3mg/kg IV (maximum 320mg)
plus Metronidazole 500mg IV
Preferred choice: Co-amoxiclav 1.2g IV
MRSA Carriage
Flucloxacillin 1g IV
or, if penicillin allergy,
Gentamicin 3mg/kg IV (maximum 320mg)
Prophylaxis not recommended
Alternative: cefuroxime 750mg
The Infection Control Team should be
consulted regarding possible eradication
therapy for adults undergoing general
surgery who are identified with MRSA or
Staph. Aureus.
MRSA positive patients should receive cover
that includes a glycopeptide (teicoplanin
400mg IV).
SIGN 104 July 2008, updated April 2014.
45
*‘High Risk’ intraoperative cholangiogram, bile spillage, conversion to laparotomy,
acute cholecystitis / pancreatitis.jaundice, pregnancy, immunosuppression, prosthesis
insertion
** ‘High Risk’ pancreatic pseudocyst, immunosuppression, incomplete biliary drainage
Urology
Transrectal prostate biopsy
Ciprofloxacin 500mg oral 60 minutes before
procedure
Transurethral resection of prostate
Gentamicin 160mg IV
TURBT (Local practice)
Gentamicin 160mg IV
Obstetrics and Gynaecology
Caesarean Section
Cefuroxime 1.5g IV + metronidazole
500mg IV.
Or, in immediate (type 1) beta-lactam
sensitivity
Clindamycin 900mg IV
Gynaecology majors, including PFRs
Gentamicin 3mg/kg IV (maximum 320mg)
plus Metronidazole 500mg IV
Termination of pregnancy
Metronidazole 1g oral or PR 2 hours before
surgery followed by Azithromycin 1g oral
single dose (unless pre-operative screening
has ruled out chlamydial infection) with
administration of Misoprostol
Transvaginal tapes
Gentamicin 3mg/kg IV (maximum 320mg)
plus Metronidazole 500mg IV
Orthopaedic Surgery
Total Joint Arthroplasty (antibiotic loaded Cefuroxime 1.5g IV
cement is also recommended in addition
to IV antibiotics)
Or, in immediate (type 1) beta-lactam
sensitivity
Teicoplanin 400mg IV
plus Gentamicin 3mg/kg IV (maximum
320mg)
Other arthroplasty procedures
Flucloxacillin 1g IV plus
Gentamicin 3mg/kg IV (maximum 320mg)
All intramedullary nails
Or in Penicillin allergy
Teicoplanin 400mg IV
plus Gentamicin 3mg/kg IV (maximum
320mg)
Other internal fixations / operations
Prophylaxis at discretion of Orthopaedic
Consultant
46
Complex, open fractures with extensive
soft tissue injury
Co-amoxiclav 1.2g IV 8 hourly for three
doses.
penicillin allergy
Teicoplanin 400mg IV 12 hourly for 3 doses
plus gentamicin 3mg/kg IV (maximum
320mg)
Follow treatment guidelines
infection suspected
Oral Surgery
Wisdom teeth extraction
High risk patients (at discretion of oral
surgeon)
Gastrointestinal Endoscopy
PEG insertion
if
ongoing
Preferred choice: Co-amoxiclav 1.2g IV
Alternative: cefuroxime 750mg IV
Co-amoxiclav 1.2g IV
Or, in penicillin allergy, teicoplanin 400mg
IV
Variceal banding (planned)
Co-amoxiclav 1.2g IV
Or, in minor penicillin allergy, cefotaxime 2g
IV. Or, in immediate (type 1) beta-lactam
sensitivity, teicoplanin 400mg IV
Gastrointestinal bleed (not strictly
prophylaxis)
Co-amoxiclav 1.2g IV 8 hourly
Or, in minor penicillin allergy, cefotaxime 2g
IV 8 hourly. Or, in immediate (type 1) betalactam sensitivity, vancomycin IV (see
appendix 1: monitoring antibiotic dosage)
plus ciprofloxacin 400mg IV 12 hourly
(consult Microbiologist if patient has been
receiving a quinolone as SBP prophylaxis).
Scottish Intercollegiate Guidelines Network Surgical Prophylaxis Guidelines
http://www.sign.ac.uk/pdf/sign104.pdf
Scottish Antimicrobial Prescribing Group. Antibiotic Prophylaxis in Surgery. June 2009.
http://www.scottishmedicines.org
British Society of Gastroenterology.Antibiotic prophylaxis in gastrointestinal endoscopy.
Gut 2009; 58: 869-880.
47
APPENDIX v
GUIDELINES FOR THE PROTECTION OF THE ADULT ASPLENIC PATIENT
Patients with functional hyposplenia or with impaired immune function should always be
referred to a Consultant Haematologist.
Patients who have their spleen removed as a result of trauma or surgery should be
considered for the following therapy.
Vaccination Schedule
Elective splenectomy
4-6 weeks pre-operatively
If this is not possible then up to 2 weeks before
procedure
Unplanned splenectomy
Vaccines
Haemophilus influenzae type b
Meningococcal
Pneumococcal
Influenza
At least 2 weeks post-operatively
One dose Hib/MenC vaccine (Menitorix) followed
by one dose MenACWY conjugate vaccine
(Menveo) one month later
Pneumococcal
polysaccharide
vaccine
(Pneumovax II)
Repeat at 5 yearly intervals
Recommended yearly for seasonal protection
Prophylactic Antimicrobials
Antimicrobials should be given for at least two years post splenectomy and consideration
given to life long prophylaxis
Phenoxymethylpenicillin (Pen V) 500mg twice daily
Penicillin allergy – Clarithromycin 250mg twice daily
Antimicrobial Treatment
In addition to prophylaxis, a supply of antimicrobials may be kept at home and used
immediately should symptoms of raised temperature, malaise or shivering illness occur.
Co-amoxiclav (Amoxicillin/clavulanic acid) 375mg 8 hourly for 7 days
Penicillin allergy
Clarithromycin 500mg 12 hourly for 7 days
Counselling
Patients should be given advice about general infection risk, foreign travel, further vaccines,
food hygiene, malaria prophylaxis, animal and tick bites and the need for prompt referral to
hospital if signs and symptoms of a febrile infection occur.
Patients should be given a patient information leaflet and a “no spleen” card for the patient to
carry.
48
APPENDIX vi
PROPHYLAXIS OF INFECTIVE ENDOCARDITIS
In the past, people at risk of infective endocarditis* have been offered antibiotics when
they have certain medical or dental procedures. NICE** has recommended a change in
practice, so now antibiotics should only be offered if the procedure is at a site where
there is a suspected infection. This is because medical and dental procedures are no
longer thought to be the main cause of endocarditis, and taking antibiotics carries its
own risk.
*Adults and Children with the following structural cardiac conditions are ‘at risk’ of
developing infective endocarditis
•
•
•
•
•
acquired valvular heart disease with stenosis or regurgitation
valve replacement
structural congenital heart disease, including surgically corrected or palliated structural
conditions but excluding isolated atrial septal defect, fully repaired ventricular septal
defect or fully repaired patent ductus arteriosus, and closure devices that are judged to
be endothelialised
hypertrophic cardiomyopathy
previous endocarditis
Advice
Offer people at risk of infective endocarditis clear and consistent information about
prevention, including:
• the benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic
prophylaxis is no longer routinely recommended
• the importance of maintaining good oral health
• symptoms that may indicate infective endocarditis and when to seek expert advice
• the risks of undergoing invasive procedures, including non-medical procedures such
as body piercing or tattooing
When to offer prophylaxis
Do not offer antibiotic prophylaxis against endocarditis:
•
•
•
•
•
to people undergoing dental procedures
to people undergoing non-dental procedures at the following sites
upper and lower gastrointestinal tract
genitourinary tract; this includes urological, gynaecological and obstetric procedures
and childbirth
upper and lower respiratory tract; this includes ear, nose and throat procedures and
bronchoscopy
Do not offer chlorhexidine mouthwash as prophylaxis against infective endocarditis to people
at risk undergoing dental procedures.
Managing infection
Investigate and treat promptly any episodes of infection in people at risk of infective
endocarditis to reduce the risk of endocarditis developing.
Offer an antibiotic that covers organisms that cause infective endocarditis if a person at risk of
infective endocarditis is receiving antimicrobial therapy because they are undergoing a
gastrointestinal or genitourinary procedure at a site where there is a suspected infection.
** NICE clinical guideline 64 Prophylaxis against infective endocarditis March 2008
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11938
49
APPENDIX vii
GUIDANCE ON SWITCHING ANTIBIOTICS FROM IV TO ORAL
Advantages of prompt switch to oral therapy include
•
Reduction in hospital acquired bacteraemia caused by infected lines. Peripheral lines
should be changed every 72 hours, or earlier if they look infected, and removed as
soon as they are no longer required.
•
Improved patient comfort and mobility
•
Oral doses are more convenient to administer, saving medical and nursing time
•
Possibility of earlier discharge from hospital
•
Improved use of resources
Considerations for early switch to oral therapy COMH (Review at 24 to 48 hours)
C
O
Clinical improvement observed
Oral route not compromised
•
•
•
M
Suitable oral formulation available
No vomiting or severe diarrhoea
No swallowing disorder, patient fully conscious (contact pharmacy for advice on
antimicrobials via PEG / NG tube)
Markers show a trend to normal
•
•
•
•
•
Temperature above 36ºC and below 39ºC, preferably normal for at least 24
hours
Heart rate less than 90 beats per minute
Blood pressure stable
Respiratory rate less than 20 breaths per minute
White cell count, where available, shows trend to normal
H
High risk / deep seated infections and/or a senior clinician or consultant microbiology
has specifically advised a longer duration of IV therapy
Certain infections may appear to respond promptly but warrant prolonged IV therapy to
optimise response and minimise risk of relapse.
Discuss with a consultant
microbiologist before switching patients with high risk/deep seated infections
For deep-seated infections an initial two High risk infections need prolonged IV therapy,
weeks of therapy may be needed. such as
Examples include
•
Staphylococcus aureus bacteraemia
•
Liver abscess
•
Necrotising soft tissue infections
•
Osteomyelitis
•
Neutropenic sepsis
•
Septic arthritis
•
Infected implants/prosthetics
•
Empyema
•
Meningitis
•
Cavitating pneumonia
•
Intracranial abscess
•
Mediastinitis
•
Endocarditis
•
Exacerbations of cystic fibrosis
•
Inadequately drained abscesses and
empyema
If the patient deteriorates on oral therapy consider return to IV and / or discuss with the
Consultant Microbiologist.
Consult Antimicrobial Guideline or contact microbiology for advice on choice of oral therapy.
50
In general:
IV Agent
Amoxicillin
Ciprofloxacin
Clarithromycin
Clindamycin
Co-amoxiclav
Flucloxacillin
Gentamicin
Metronidazole
Rifampicin
Teicoplanin/Vancomycin/Meropenem/Tazocin
Oral
Amoxicillin 500mg-1g 8 hourly
Ciprofloxacin 500mg 12 hourly
(750mg 12 hourly if pseudomonas
suspected)
Clarithromycin 500mg 12 hourly
Clindamycin 300-450mg 6 hourly
Co-amoxiclav 375-625mg 8 hourly
Flucloxacillin 500mg-1g 6 hourly
None equivalent – change as indicated by
sensitivities or microbiology advice
Metronidazole 400mg 8 hourly
Rifampicin 0.6-1.2g daily in 2-4 divided doses
None equivalent – change as indicated by
sensitivities or microbiology advice
*The above table applies only to patients with normal renal function. Doses should be
adjusted according to severity of infection. Check for microbiology sensitivity results.
References:
1. http://www.bsac.org.uk/pyxis
2. Sevinc F et al. Early switch from intravenous to oral antimicrobials:
Guidelines implementation in a large teaching hospital JAC 1999; 43:601-666
51
APPENDIX viii
PROTOCOL FOR MANAGEMENT OF PATIENTS WITH NEUTROPENIC SEPSIS AT BORDERS GENERAL
HOSPITAL
Introduction
Patients with fever and neutropenia are at major risk of developing potentially fatal
septicaemia. Immediate treatment with intravenous antibiotics is ESSENTIAL if the patient is
to be protected from this complication.
Patients at risk of neutropenic sepsis
•
•
•
•
Receiving myelotoxic chemotherapy
Condition which leads to a reduction in neutrophil numbers and / or function
May be inpatients anywhere in BGH or may be outpatients
NB: Patients receiving chemotherapy as day cases are instructed to seek medical
advice if they become unwell and / or develop a fever. If these patients or their
relatives or GP / nurse make contact with duty medical / nursing staff at BGH it is
ESSENTIAL that they are advised to attend without delay
Definition of neutropenic sepsis
Fever of 38°C or above on two separate occasions at least one hour apart, or a single episode
of fever >38.5°C
PLUS
Neutrophils of less than1.0 x 10 9/1 or higher than that but likely to decline to 1.0 or less.
Clinical Assessment
Take a careful history with special regard to Date of any last chemotherapy
Symptoms of infections (e.g. cough, dysuria)
Any previous episodes of fever
Any severe allergies to antibiotics (not simply minor rash)
Full clinical examination, special points are –
Check Hickman line sites
Examine mouth and perineum (no digital rectal examination)
Fundoscopy for retinal haemorrhage (platelets may be low)
Patient needs to be WEIGHED for calculation of Gentamicin dose (see below)
Investigations
Swab any infected site, including Hickman line site
MSU
Chest X-Ray
Sputum (where available) for culture
Stool culture and Clostridium difficile toxin if diarrhoea present
Repeat FBC, U+E LFT CRP Coagulation screen, Group and Save
Blood cultures – peripheral plus from any central line if present
Pulse oximetry, arterial blood gases if saturation <92%
52
Treatment
Set up IV drip and ensure adequate fluid resuscitation. Typically patients will require up to 3
litres of crystalloid in 24 hours. Colloid may be needed to support blood pressure.
IMMEDIATE IV antibiotics once blood cultures are taken
Piperacillin/tazobactam (Tazocin) 4.5G 6 HOURLY (check no Penicillin allergy)
In addition to above:
Rx Gentamicin extended interval dosing (see Appendix i – Monitoring Antimicrobial
Dosage)
Note: Patients receiving nephrotoxic chemotherapy, e.g. Carboplatin or Cisplatin should
not receive Gentamicin. Consult Microbiologist or Haematologist for advice.
If known severe beta-lactam allergy seek advice from Consultant Microbiologist. A
combination of Glycopeptide (Vancomycin or Teicoplanin) with Gentamicin and Metronidazole
may be appropriate. If the beta-lactam reaction consists of a rash only it should be safe to
replace piperacillin/tazobactam + Gentamicin with Ceftazidime 2g TDS + Gentamicin.
If clinically obvious Hickman line infection add teicoplanin 400mg daily (plus additional dose
at 12 hours). (Check dose with microbiologist as in some cases10mg/kg required). Discuss
with Consultant Haematologist with respect to removing the line.
Rx Oxygen as needed.
Careful fluid balance – daily weight where possible.
Neutropenic patients on long term methotrexate treatment should be given folinic acid rescue.
See Rheumatology Service Guidelines.
INFORM THE DUTY CONSULTANT HAEMATOLOGIST REGARDLESS OF TIME OF DAY
OR NIGHT.
53
APPENDIX ix RENAL IMPAIRMENT AND ANTIBIOTICS
1
For patients receiving renal dialysis (haemodialysis, CAPD) refer to manufacturers’ recommendations and renal unit guidelines.
Contact pharmacy for advice.
For renal replacement therapy on ITU see ITU guidelines.
Drug/Dose in normal
renal function
Amoxicillin PO
500mg 8 hourly
Degree of renal impairment (CrCl) and dosage adjustment
Comments
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
dose as in normal renal function
<10 ml/min
250-500mg 8 hourly
Amoxicillin IV
500mg-1g 8 hourly
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
dose as in normal renal function
<10 ml/min
250-1g 8 hourly (max. 6g
per day in endocarditis)
Sodium content of Injection
3.3 mmol/g vial of Amoxil
Benzylpenicillin
600mg – 3.6g 6 hourly
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
600mg-2.4g 6 hourly
<10 ml/min
600mg-1.2g 6 hourly
600mg contains
1.68mmol of
Sodium
10-20 ml/min
50-100% of normal dose
<10 ml/min
50% of normal dose
10-20 ml/min
50-100% of normal dose
<10 ml/min
50% of normal dose
30-50ml/min
dose as in normal
renal function
10-30 ml/min
250-500 mg 12 hourly
<10 ml/min
250-500mg 12 hourly
30-50ml/min
dose as in normal
renal function
10-30 ml/min
dose as in normal renal function
<10ml/min
dose as in normal renal
function
30-50ml/min
dose as in normal
renal function
10-30ml/min
1.2g 12 hourly
<10ml/min
1.2g stat followed by
600mg
8 hourly or 1.2g 12 hourly
Ciprofloxacin PO
250-750mg 12 hourly
Ciprofloxacin IV
100-400mg 12 hourly
Clarithromycin IV/PO
500mg 12 hourly
Co-amoxiclav PO
375-675mg 8 hourly
Co-amoxiclav IV
1.2g 8 hourly
20-50ml/min
dose as in normal
renal function
20-50ml/min
dose as in normal
renal function
54
Drug/Dose in normal
renal function
Degree of renal impairment (CrCl) and dosage adjustment
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
dose as in normal renal function
<10 ml/min
50-75% of normal dose
Flucloxacillin PO
250mg-500mg 6 hourly
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
dose as in normal renal function
<10 ml/min
dose as in normal renal
function
Flucloxacillin IV
250mg – 2g 6 hourly
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
dose as in normal renal function
Fluconazole
50-400mg daily
20-50 ml/min
dose as in normal
renal function
<10 ml/min
dose as in normal renal
function (max. total daily
dose of 4g)
<10 ml/min
50% of normal dose
Meropenem IV
500mg-1g 8 hourly
20-50ml/min
500mg-2g 12 hourly
Metronidazole PO
200-400mg 8 hourly
Erythromycin
500mg qds
10-20 ml/min
dose as in normal renal function
10-20 ml/min
500mg – 1g 12 hourly
or 500mg 8 hourly
<10
500mg – 1g 24 hourly
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
dose as in normal renal function
<10 ml/min
dose as in normal renal
function
Metronidazole IV
500mg 8 hourly
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
dose as in normal renal function
<10 ml/min
dose as in normal renal
function
Penicillin V
250mg –1000mg 6
hourly
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
dose as in normal renal function
<10 ml/min
dose as in normal renal
function
Piperacillin/tazobactam
4.5g 6-8 hourly
20-50 ml/min
dose as in normal
renal function
10-20 ml/min
4.5g 8-12 hourly or
2.25g 6 hourly
15-27 ml/min
200mg 12 hourly for three days
then 100mg 12 hourly
<10 ml/min
4.5g 12 hourly or
2.25g 8 hourly
Comments
Sodium content of injection
2.26mmol/g
Sodium content 14mmol in
500mg/100ml injection
>27 ml/min
<15ml/min
th
From Martindale 37 ed.
dose as in normal
100mg 12 hourly
renal function
1
rd
Suggested doses from the Renal Drug Handbook, 3 ed (2009), C. Ashley & A. Currie, eds) unless otherwise stated.
Trimethoprim
200mg 12 hourly
55