Download Adult Antibiotic Guidelines Secondary Care

Aneurin Bevan Health Board
Adult Antibiotic Guidelines
Secondary Care
Please note:
The Antibiotic Prophylaxis Guideline full document is available on the intranet
N.B.
Staff should be discouraged from printing this document. This is to
avoid the risk of out of date printed versions of the document. The
Intranet should be referred to for the current version of the document.
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Owner: Antimicrobial Working Group
Issue date: 4 March 2013
Review by date: 4 March 2016
Policy Number: ABHB/Clinical/0008
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
1
ABHB/Clinical/0008
Executive Summary
These guidelines provide an overview of recommended antibiotics for
empirical use within the organisation.
1.1
Scope of guidelines
These guidelines apply to adult in-patients prescribed antibiotics.
2
Aims
These guidelines aim to provide prescribers with guidance to ensure that
empiric antibiotic prescribing is appropriate and cost effective.
3 Policy Statement
These guidelines aim to improve the quality of prescribing of antibiotics within
the organisation.
4 Responsibilities
It is the prescriber’s responsibility to check appropriateness of agents used
taking into account co-existing conditions or medication. All prescribers and
pharmacists have a responsibility to ensure empiric antibiotic prescribing is
guided by the health board’s antibiotic guidelines.
5 Training
No formal training is required on these guidelines. New members of medical
and pharmacy staff and other prescribers within the organisation will be
advised on how to access the guidelines on their induction.
6 Audit
The guidelines will be audited by the antibiotic working group or pharmacy
annually. The results will be fed back to the antibiotic working group, which
will agree an appropriate strategy dependant on audit results.
7 Further Information
Further information can be obtained from the Antimicrobial Pharmacist based
in the pharmacy department.
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 1 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
Contents
1
2
2
3
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
24
25
26
26
27
28
29
30
Condition
Community-acquired pneumonia
Infective exacerbations of COPD
Infective exacerbation of asthma
Aspiration pneumonia
Hospital-acquired pneumonia
Clostridium difficile-associated diarrhoea
Intra-abdominal infections (cholecystitis, peritonitis,
hepato-bilary)
Hepatic abscess
Spontaneous bacterial peritonitis
Gastroenteritis
Cellulitis
Diabetic foot ulcer
Infected human or animal bite
Breast – lactational mastitis
Non lactational breast sepsis
Suspected necrotising fasciitis
Urinary tract infections – Community acquired,
uncomplicated
Urinary tract infections – Hospital-acquired
Pyelonephritis (includes patients with an indwelling
catheter)
Acute bacterial prostatitis
Epididymo-orchitis
Meningitis
Endocarditis
Sepsis (unknown origin)
Neutropenic sepsis
Osteomyelitis
Septic arthritis
Prosthetic joint infection
Open fracture
Dirty wound
Aminoglycosides & Vancomycin dosing information
Antimicrobial prophylaxis summary
Antimicrobial dosing guidelines in adults with renal
impairment and failure
Gentamicin administration charts
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 2 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
Antibiotic Prescribing
These guidelines have been revised in response to concerns nationally and locally over the
rates of Clostridium difficile infection. Cephalosporins and fluoroquinolones have been
particularly associated with a higher risk of C. difficile, but all broad-spectrum antibiotics are
potentially hazardous for this infection.
The routine use of cefuroxime, cefalexin and ciprofloxacin is not recommended. The
use of these antibiotics should be limited to treating conditions where there are no
alternatives that provide adequate cover or when their use is explicitly recommended
in this guide.
Whenever possible, relevant specimens for culture must be taken from in-patients
before starting antibiotics.
•
ALL antibiotics prescribed on a chart must have the intended DURATION or date for
review specified in the special instructions section of the drug chart.
•
Antibiotics should be given for the complete course prescribed and doses should not
be omitted.
•
Restricted antibiotics should be approved by microbiology before prescribing (See
below).
•
Oral antibiotics prescribed for 5 days will be stopped according to the criteria in the
antibiotic automatic stop policy unless the duration is specified.
•
All recommended doses are for ADULT in-patients with normal renal and liver
function.
Restricted antimicrobials
The following antimicrobials are restricted within the organisation according to the
restricted antimicrobial policy. If they are prescribed for an indication or patient group
that is not listed in the exemptions in the restricted antimicrobial policy please contact
microbiology to obtain approval for their use.
Amphotericin, Caspofungin, Ciprofloxacin (IV),
Doripenem, Ertapenem, Fidaxomicin*, Fluconazole
(IV), Imipenem/Cilastatin, Levofloxacin, Linezolid,
Meropenem, Pivmecillinam, Teicoplanin, Tigecycline,
Voriconazole
The restricted antimicrobial policy does NOT apply to:
paediatric, haematology, critical care or neutropenic patients
* Fidaxomicin requires approval by consultant microbiologist in all cases
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 3 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
1. Community-acquired pneumonia
Antibiotic Treatment
Advised
Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Mild (CURB-65 < 1)
Mild (CURB-65 < 1)
Amoxicillin PO 500mg tds
7 days
Moderate (CURB-65 = 2)
7 days
Doxycycline PO 200mg
loading dose then PO
100mg od, or
clarithromycin PO 500mg
bd
Moderate (CURB-65 = 2)
Amoxicillin PO 500mg to 1g tds plus
clarithromycin PO 500mg bd
Doxycycline PO 200mg
loading dose then PO
100mg od, or
clarithromycin PO 500mg
bd
If oral administration is not
possible and
cephalosporins are
considered satisfactory
having considered the
nature of the allergy:
Or if oral administration not possible:
Amoxicillin IV 500mg tds plus
clarithromycin IV 500mg bd
Cefuroxime IV 1.5g tds plus
clarithromycin IV 500mg bd
In severe anaphylaxis:
Levofloxacin IV 500mg bd
Severe (CURB-65 > 3)
Severe (CURB-65 > 3)
Benzylpenicillin IV 1.2g qds plus
clarithromycin IV/PO 500mg bd. Review IV need
daily.
If life-threatening infection, significant comorbidities, risk of Gram negative infection or care
home resident:
Co-amoxiclav IV 1.2g tds and
Clarithromycin IV/PO 500mg bd. Review IV need
daily.
Contact microbiology
7 to 10
days
May extend
to 14 to 21
days if
Staphyloco
ccal or
Gram-neg
infection
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 4 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
Antibiotic Treatment
ABHB/Clinical/0008
Advised
Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Comments/References
ALWAYS check and record the CURB-65 score
Recent onset Confusion
Urea >7
Resp Rate>30
BP systolic <90 or diastolic <60
Age>65 years
BTS Guidelines: Thorax 2009; v64 (Suppl III); iii1-iii55. doi:10.1136/thx.2009.121434
2. Infective exacerbations of COPD and asthma with no signs of
pneumonia on X-ray
Antibiotic Treatment
Advised Total
Duration
Amoxicillin PO 500mg tds
Mild or
Moderate
exacerbation:
5 days
Severe
exacerbation:
7 days
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 5 of 26
Alternatives for Penicillin
allergic patients (patient has
had an anaphylactic reaction)
Doxycycline PO 200mg stat
then 100mg od
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
3. Hospital-acquired pneumonia and aspiration pneumonia
Aspiration pneumonia
Antibiotic Treatment
Advised Total
Duration
Co-amoxiclav IV/PO (IV 1.2g tds/ PO 625mg tds)
Contact microbiology if patient does not respond in 24
hours
7 days
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Doxycycline PO 200mg stat
then doxycycline PO 100mg
bd
Hospital-acquired pneumonia that presents < 5 days after admission, and has not
received antibiotics in last 10 days
Antibiotic Treatment
Advised Total
Duration
Co-amoxiclav IV/PO (IV 1.2g tds/ PO 625mg tds)
Contact microbiology if patient does not respond in 24
hours
7 days
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Doxycycline PO 200mg stat
then doxycycline PO 100mg
bd
Hospital-acquired pneumonia that presents > 5days after admission, or has received
antibiotics within last 10 days, or has co-morbidities
Antibiotic Treatment
Advised Total
Duration
Piperacillin/tazobactam IV 4.5g tds. Switch to oral
treatment with co-amoxiclav PO 625mg tds or
according to culture and sensitivities
Alternatives for Penicillin
allergic patients (patient has
had an anaphylactic
reaction)
Please discuss with
microbiology
Comments/References
Always review previous microbiology results. Check organisms and sensitivities – if known MRSA,
Pseudomonas or multi-resistant gram organisms different antibiotics likely to be required..
Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working
Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy J.
Antimicrob. Chemother. 2008 62: 5-34
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 6 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
4. Clostridium difficile-associated diarrhoea
Antibiotic Treatment
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Where possible STOP all other antibiotics and PPIs
Non-severe
Metronidazole PO 400mg tds
May be repeated once more if a non-severe relapse
occurs.
Daily assessment is required.
10 days
Symptoms not improving or
worsening should not be
deemed a treatment failure
until received a few days of
treatment.
If symptoms not improving or are worsening, or a third
episode occurs, switch to the ‘severe’ treatment course.
9
Severe (WBC > 15x10 /L, acutely rising creatinine
and/or signs or symptoms of colitis)
Vancomycin PO 125mg qds
10 days, may
be extended
according to
response
Anti-motility agents should not
be prescribed unless
recommended by
gastroenterologist.
If symptoms not improving or relapse occurs, contact
Surgical/GI/Micro for consultation on use of high-dose
vancomycin, tapering regimes, combination therapy or
fidaxomicin.
Comments/References
See also Clostridium difficile Policy (available on intranet) or Department of Health guidelines.
5. Intra-abdominal infections (cholecystitis, peritonitis, hepato-bilary)
Antibiotic Treatment
Advised Total
Duration
Amoxicillin IV 1g tds and gentamicin IV 5mg/kg od
(check levels) and metronidazole IV 500mg tds.
Minimum of 5 days of IV treatment. Switch to oral
treatment with co-amoxiclav PO 625mg tds.
If gentamicin is contra-indicated use the following
combination:- Piperacillin / tazobactam IV 4.5g tds and
metronidazole IV 500mg tds
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Teicoplanin IV 400mg 12
hourly for three doses then
400mg od and gentamicin IV
5mg/kg od (check levels) and
metronidazole IV 500mg tds.
Contact microbiology to
discuss choice of oral
treatment.
If gentamicin is contraindicated please contact
microbiology
Comments/Reference
See section 27 (aminoglycosides). Maximum dose for once daily Gentamicin is 560mg.
6. Hepatic abscess
Antibiotic Treatment
Advised Total
Duration
Metronidazole IV 500mg tds and
piperacillin / tazobactam IV 4.5g tds (switch to oral
treatment with co-amoxiclav PO 625mg tds if
sensitivities known otherwise contact microbiology)
Discuss with
microbiology
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 7 of 26
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Contact microbiology for
advice
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
7. Spontaneous bacterial peritonitis
Treatment of spontaneous bacterial peritonitis
Antibiotic Treatment
Advised Total
Duration
Piperacillin / tazobactam IV 4.5g tds
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Tigecycline IV 100mg stat
then IV 50mg bd
Prophylaxis of spontaneous bacterial peritonitis
Antibiotic Treatment
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Co-trimoxazole PO 960mg od for 5 days per week
Comments/References
If there is an issue with compliance then co-trimoxazole can be prescribed PO 960mg daily, without the two
day break
8. Gastroenteritis
Antibiotic Treatment
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Antibiotics not recommended unless a particular cause,
e.g. Clostridium difficile suspected
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 8 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
9. Cellulitis
Mild to moderate cellulitis
Antibiotic Treatment
Advised Total
Duration)
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Clarithromycin IV 500mg bd.
Minimum of 4 days of
intravenous therapy. Switch to
oral clarithromycin PO 500mg
bd.
Flucloxacillin IV 1g qds (treat intravenously for a
minimum of 48 hours before considering a switch to oral
treatment flucloxacillin PO 1g qds)
NB Mild cases with no systemic toxicity and no
uncontrolled co-morbidities can be treated orally as an
outpatient.
Comments/References
Flucloxacillin alone provides adequate cover for streptococci in mild to moderate cases.
Cellulitis in a patient with risk factors for MRSA
Antibiotic Treatment
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient has
had an anaphylactic
reaction)
Vancomycin IV (check levels)
Comments/Reference
See section 27 for vancomycin dosing.
Severe cellulitis
Antibiotic Treatment
Advised Total
Duration
Flucloxacillin IV 1g qds and benzylpenicillin IV 2.4g 4-6
hourly
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Vancomycin IV (check
levels) and clindamycin IV
300-600mg bd-qds (see
comments )
Comments/References
Discontinue clindamycin immediately if diarrhoea or colitis develops.
For classification of cellulitis see: Eron, L. J. 2003. The admission, discharge and oral switch decision
processes in patients with skin and soft tissue infections. Current Treatment Options in Infectious Diseases,
5: 245-250.
See section 27 for vancomycin dosing.
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 9 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
10. Diabetic foot ulcer
Note that many of the drugs used here have significant risks for diarrhoea, drug interactions,
and renal, liver, ocular or bone marrow toxicity. Assiduous vigilance and monitoring is
required.
Good quality microbiological specimens are critical in managing these infections.
A separate detailed Diabetic Foot Care Pathway is also available.
No infection (Pedis Grade 1)
Antibiotic Treatment
None – Use local dressings and regular podiatry
Mild infection (Pedis Grade 2) – mild infection, cellulitis <2 cm, infection confined to
skin and subcutaneous tissues and NOT systemically unwell.
Antibiotic Treatment
Advised Total
Duration
Flucloxacillin PO 1g qds
5 to 7 days, then
adjust in light of
culture results and
clinical response
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Doxycycline PO 100mg bd or
Clindamycin PO 300mg qds
Comments/References
Antimicrobial dressings are recommended, such as Inadine. Improve glycaemic control and non-weight
bearing. Suitable to be treated in the community.
Moderate infection (Pedis Grade 3) – mild infection, cellulitis >2 cm, lymphatic
streaking, deep tissue or bone infection and NOT systemically unwell.
Antibiotic Treatment
No antibiotic given within the last month:
Flucloxacillin PO 1g qds plus (if anaerobes suspected)
Metronidazole PO 400mg tds
Antibiotic given within the last month:
If suitable for oral therapy:
Either Clindamycin PO 300mg qds plus Ciprofloxacin
PO 500mg bd;
or (if Pseudomonas not suspected):
Co-amoxiclav PO 625mg tds +/– amoxicillin 500mg PO
tds
Advised Total
Duration
Alternatives for Penicillin
allergic patients or other
contra-indications
Minimum 10 to
14 days
Clindamycin PO 300mg600mg qds
Osteomyelitis
minimum 4-6
weeks
If IV therapy required:
Either: (if Pseudomonas not suspected): Co-amoxiclav
IV 1.2g tds, with switch to oral 625mg tds +/–
amoxicillin 500mg tds after 5-7 days;
Or: Vancomycin IV (measure levels) plus Ciprofloxacin
IV 400mg tds plus Metronidazole IV 500mg tds, with
switch to oral Linezolid PO 600mg bd plus Ciprofloxacin
PO 500mg-750mg bd plus Metronidazole PO 400mg
tds
Linezolid PO 600mg bd plus
Ciprofloxacin PO 500mg750mg bd plus Metronidazole
PO 400mg tds
Vancomycin IV (measure
levels) plus Ciprofloxacin IV
400mg tds plus Metronidazole
IV 500mg tds, with switch to
oral Linezolid PO 600mg bd
plus Ciprofloxacin PO 500mg750mg bd plus Metronidazole
PO 400mg tds
Comments/References
See section 27 for vancomycin dosing.
Antimicrobial dressings, debridement, improved glucose control and non-weight bearing are also
recommended.
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 10 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
Severe infection – SYSTEMICALLY UNWELL / SEPSIS SYNDROME (Pedis Grade 4)
Antibiotic Treatment
No antibiotic given within the last 90 days:
Co-amoxiclav IV 1.2g tds plus Gentamicin IV 5mg/kg
Antibiotic given within the last 90 days:
Vancomycin IV (substitute with Teicoplanin if renal
function very poor) plus either Piperacillin / tazobactam
IV 4.5g tds (if ESBL coliforms never documented), or
plus Meropenem IV 1g tds.
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Minimum 10 to
14 days
Vancomycin IV (substitute
with Teicoplanin if renal
function very poor) plus
Ciprofloxacin IV 400mg bd
plus Metronidazole IV 500 mg
tds
Osteomyelitis
minimum 4-6
weeks
Oral switch when clinically appropriate:
Ciprofloxacin PO 500mg-750mg bd plus
Metronidazole PO 400mg tds plus
either Linezolid PO 600mg bd
or Rifampicin* PO 300mg bd with one of: Doxycycline
PO 100mg bd, or with Fusidic acid* PO 500mg tds, or
with Trimethoprim PO 200mg bd
Comments/References
Take blood cultures and cultures from deep curettage or debridement tissue rather than superficial swabs.
Adjust antibiotic regime based on culture results.
* Need for hepatic monitoring. Do not use Rifampicin or Fusidic acid alone for staphylococcal therapy as
there is a high risk of resistance development.
See section 27 (aminoglycosides and vancomycin) and section 29 (other drugs) for renal dose adjustments.
Maximum dose for once daily Gentamicin is 560mg.
Diabetic foot ulcers with suspected or proven MRSA
Antibiotic Treatment
Advised
Total
Duration
Alternatives for Penicillin
allergic patients (patient has
had an anaphylactic
reaction)
Add Vancomycin IV (check levels) or (if renal function
very poor) Teicoplanin IV/IM 400mg od after 3 doses 12
hours apart
If MRSA osteomyelitis suspected, also add:
Rifampicin* PO/IV 600mg bd or Fusidic acid* PO 500mg
tds (check LFTs)
Oral switch when clinically appropriate:
either Doxycycline PO 100mg bd (possibly with Fusidic
acid* PO 500mg tds if dual therapy required)
or Linezolid PO 600mg bd
or Rifampicin* 300mg PO bd plus one of: Doxycycline PO
100mg bd, or with Fusidic acid* PO 500mg tds, or with
Trimethoprim PO 200mg bd
Comments/References
* Need for hepatic monitoring. Do not use Rifampicin or Fusidic acid alone for staphylococcal therapy as
there is a high risk of resistance development.
See section 27 (vancomycin).
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 11 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
11. Infected human or animal bite
Antibiotic Treatment
Advised Total
Duration
Co-amoxiclav PO 625mg tds
5 days
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Consult microbiology
12. Breast - lactational mastitis
Antibiotic Treatment
Advised Total
Duration
Flucloxacillin IV/PO 1g qds (if mild and treated as
outpatient PO 500mg qds)
7 days
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Clarithromycin PO 500mg bd
13. Non lactational breast sepsis
Antibiotic Treatment
Advised Total
Duration
Co-amoxiclav IV/PO (IV dose 1.2g tds/ PO dose 625mg
tds)
7 days
Alternatives for Penicillin
allergic patients (patient has
had an anaphylactic
reaction)
Clarithromycin IV/PO 500mg
bd and metronidazole IV/PO
(IV 500mg tds/ PO 400mg tds)
14. Suspected necrotising fasciitis
Antibiotic Treatment
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Discuss with surgeons and microbiology
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 12 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
15. Urinary tract infections- Male and female community acquired
(without systemic symptoms)
Antibiotic Treatment
st
1 Line: Trimethoprim po 200mg bd, unless elderly
(over 65) or have had antibiotics within the last 3
months, when the risk of a resistant organism is higher.
Advised Total
Duration
Female: 3 days
Male: 7 days
Alternatives
nd
2 Line: Nitrofurantoin PO 50mg qds (see comments)
Comments/References
Nitrofurantoin is contra-indicated in patients with CrCl <20mL/min, and not generally recommended if CrCl
<50 mL/min. Consider use of Co-amoxiclav or Pivmecillinam if Trimethoprim is also contra-indicated.
Calculator for creatinine clearance can be found in the renal dose section (section 29) and on the Clinical
Portal.
If patients are showing systemic symptoms then treat as hospital-acquired urinary tract infection.
16. Hospital-acquired urinary tract infection
Antibiotic Treatment
Advised Total
Duration
Alternatives
Gentamicin IV 5mg/kg stat then antibiotic choice based
on urine sensitivities, available within 24 hours.
Comments/Reference
If patient unable to have Gentamicin contact microbiology to discuss.
See section 27 (aminoglycosides). Maximum dose for once daily Gentamicin is 560mg.
17. Pyelonephritis (includes patients with an indwelling catheter)
Antibiotic Treatment
Advised Total
Duration
Co-amoxiclav IV/PO (IV dose 1.2g tds/ PO dose 625mg
tds).
14 days
Continue IV until temperature resolves.
If no response after 24 hours or sepsis add gentamicin
IV 5mg/kg od (check levels).
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Gentamicin IV 5mg/kg od
(check levels)
If patient unable to have
gentamicin please contact
microbiology to discuss. Once
sensitivities are reported
switch to oral antibiotics
according to sensitivities.
Comments/References
For patients with chronic urinary conditions please review previous sensitivities. Ensure all patients with a
UTI are well hydrated.
See section 27 (aminoglycosides). Maximum dose for once daily Gentamicin is 560mg..
18. Acute bacterial prostatitis
Antibiotic Treatment
Advised Total
Duration
Ciprofloxacin PO 500mg bd
14 days
More severe cases
2 – 4 weeks
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 13 of 26
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
19. Epididymo-orchitis in adults
Antibiotic Treatment
If risk of STD:
Ceftriaxone 500mg IM single dose and doxycycline PO
100mg bd
If STD not suspected:
Ciprofloxacin PO 500mg bd
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
14 days
Azithromycin 1g PO single
dose plus Ciprofloxacin PO
500mg bd
21 days
20. Meningitis
Antibiotic Treatment
Advised Total
Duration
Ceftriaxone IV 2g bd
7-21 days
depending on
organism
grown
For patients with other risk factors: >55 years, alcohol,
Pregnant - please discuss with microbiology
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Consult microbiology
Comments/References
It is statutory requirement to notify the Health Protection Team (Public Health) on 01495 332219 or via
ambulance control out of hours.
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 14 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
21. Endocarditis
Blood cultures are a cornerstone of diagnosis and should be taken prior to starting treatment
in all cases. In sub-acute presentation, three sets of blood cultures should be taken over 12
hours from peripheral sites prior to commencing antimicrobial therapy. In acute presentation
take two sets one hour apart and start antibiotics.
Key Reference: Guidelines for the diagnosis and antibiotic treatment of endocarditis in
adults. Journal of Antimicrobial Chemotherapy, 2012, v67, pp269-289.
Native Valve – indolent presentation
Antibiotic Treatment
Advised
Total
Duration
Amoxicillin IV 2g 4 hourly and (optional) gentamicin IV
1mg/kg bd. (check gentamicin levels)
Alternatives for Penicillin
allergic patients (patient has
had an anaphylactic reaction)
Vancomycin IV and gentamicin IV
1mg/kg bd (check vancomycin &
gentamicin levels)
Comments/Reference
See section 27 (aminoglycosides & vancomycin dosing). The use of gentamicin is optional before culture
results are available. If patient is stable, ideally wait for blood culture results.
Native Valve, severe shock but no risk factors for Enterobacteriaceae, Pseudomonas.
Antibiotic Treatment
Advised
Total
Duration
Vancomycin IV and gentamicin IV 1mg/kg bd
(check vancomycin and gentamicin levels)
Alternatives
Consult microbiology if
vancomycin allergy or gentamicin
is contraindicated
Comments/Reference
See section 27 (aminoglycosides & vancomycin dosing).
Native Valve, severe shock with risk factors for Enterobacteriaceae, Pseudomonas.
Antibiotic Treatment
Advised
Total
Duration
Vancomycin IV and Meropenem IV 2g 8 hourly ‡
(check vancomycin levels)
Alternatives for Penicillin
allergic patients (patient has
had an anaphylactic reaction)
Consultant microbiology
Comments/Reference
See section 27 (vancomycin dosing) ‡ See section 29 (meropenem in renal impairment).
Prosthetic valve endocarditis pending blood cultures or if negative blood cultures
Antibiotic Treatment
Advised
Total
Duration
Alternatives
Consult microbiology if
vancomycin allergy or gentamicin
is contraindicated
Vancomycin IV and gentamicin IV 1mg/kg bd and
rifampicin IV or PO 300mg-600mg bd (use the lower
rifampicin dose if severe renal impairment)
(check LFTs, vancomycin and gentamicin levels)
Comments/References
See section 27 (aminoglycosides & vancomycin dosing).
Patient with additional risk factors for staphylococcus (IV drug user, dialysis)
Antibiotic Treatment
Advised
Total
Duration
Vancomycin IV and gentamicin IV 80mg tds (If patient
<60kg reduce dose to 60mg)
(check vancomycin and gentamicin levels)
Comments/References
See section 27 (aminoglycosides & vancomycin dosing).
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 15 of 26
Alternatives
Consult microbiology if
vancomycin allergy or gentamicin
is contraindicated
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
22. Sepsis
Unknown origin
Antibiotic Treatment
Advised Total
Duration
Co-amoxiclav IV 1.2g tds and gentamicin IV 5mg/kg od
(monitor levels)
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Contact microbiology
If patient is renally impaired (CrCl < 30mL/min):
Piperacillin / tazobactam IV. Please refer to section 29
for dosing in renal impairment.
Comments/References
If patient has neutropenic sepsis then refer to neutropenic sepsis guidelines.
Blood cultures should be taken prior to first dose given and results should be reviewed within 24 hours.
See section 27 (aminoglycosides). Maximum dose for once daily Gentamicin is 560mg.
Unknown origin with history of ESBL coliform infection
Antibiotic Treatment
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Tigecycline IV initially 100mg
stat then 50mg every 12
hours.
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Contact microbiology
st
1 Line: Imipenem/cilastatin IV 500mg/500mg qds
Comments/References
Take cultures prior to first dose.
Review antibiotic choice once cultures are available.
23. Neutropenic sepsis
Antibiotic Treatment
Refer to Integrated Care Pathway –Neutropenic Fever
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 16 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
24. Osteomyelitis and Septic arthritis
Antibiotic Treatment
Advised Total
Duration
Flucloxacillin IV 1-2g qds and sodium fusidate PO
500mg tds
4-6 weeks
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Contact microbiology
Comments/References
Consider alternatives once cultures available
High risk patients (see comments) or confirmed Gram-negative infection
Antibiotic Treatment
Advised Total
Duration
Contact microbiology
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Contact microbiology
Comments/References
High risk cases: prostheses, immuno-compromised, diabetic, IVDU, catheter related bloodstream infection.
25. Prosthetic joint infection
Antibiotic Treatment
Vancomycin IV (check levels) and rifampicin IV 300600mg bd (check LFTs are normal)
Advised Total
Duration (IV
and oral)
Consult
orthopaedic
surgeon
Alternatives
Advised Total
Duration
Alternatives for Penicillin
allergic patients (patient
has had an anaphylactic
reaction)
Consult medical
microbiologist
Comments/References
See section 27 (vancomycin dosing).
26. Open fracture or dirty wound
Antibiotic Treatment
Co-amoxiclav IV/PO (IV dose 1.2g tds/ PO dose 625mg
tds)
Comment:: Give Tetanus prophylaxis. Infections often polymicrobial.
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 17 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
27. Aminoglycosides & Vancomycin – Guidelines for dosing
Calculations required for determining ideal body weight and creatinine
clearance:
Ideal body weight:
Males:
IBW = 50kg + 0.9kg for every cm over 152cm
Females:
IBW = 45.5kg + 0.9kg for every cm over 152cm
If patient’s actual body weight is 30% more than IBW:
Adjusted body weight = IBW + 0.4(Actual body weight – IBW)
Creatinine clearance:
Aminoglycoside and vancomycin dosing is dependent on a patient’s renal
function. This can be approximated by calculating the creatinine clearance
using the Cockcroft–Gault equation:
Creatinine clearance (mL/min) = (140–age in years) x weight (kg) x (1.25 for men)
Serum creatinine (micromoles per litre)
Gentamicin
The majority of patients should receive gentamicin once daily. Exclusion
criteria for once daily dosing include: severe renal impairment, pregnancy and
post-partum women, endocarditis, dialysis, ascites, cystic fibrosis and major
burns (more than 20% of body).
Gentamicin once daily dosing
In patients with normal renal function give 5mg/kg ideal body weight
(maximum of 560mg) to the nearest 40mg increment. Neutropenic policy
exempt: states 6mg/kg od.
Appropriate dosing is given in the table below:
Creatinine
clearance
(mL/min)
Gentamicin
>70
5mg/kg OD
and monitor
levels
30-70
3-5mg/kg
OD and
monitor
levels
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 18 of 26
10-30
2-3mg/kg OD
and monitor
levels
5-10
2mg/kg every
48-72 hours
according to
levels
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
Serum level measurement for once daily dosing:
All levels should be taken prior to next dose (pre-dose levels). Peak dose
levels are not required. First level should be taken prior to the third dose at
the latest unless the patient is acutely unwell where the level should be taken
prior to the second dose. Sample creatinine should be checked every other
day and increase frequency of levels if renal function worsens. If patient is
renally stable and the dose was not altered then assay every 5-7 days.
Adjust dose depending on gentamicin level as shown in table below.
Gentamicin
Once daily dosing
Ideal range
Level too high
Pre-dose (mg/L)
(Trough level)
<1
Reduce frequency
Gentamicin multiple daily dosing
To be used by patients excluded from once daily dosing
Dose: 3 to 5mg/kg IBW (Ideal Body Weight) per day in divided doses, every 8
or 12 hours — usually 120mg loading dose, then 80mg or 120mg every 8 to
12 hours. Dose to nearest 40mg increment.
Serum level measurement for multiple daily dosing:
Check both pre-dose and post-dose levels after the third dose. If patient is
renally stable and no adjustments were required, assays should be taken
every 3-5 days. Levels will need to be taken more regularly in renal
impairment and in deteriorating patients. Adjust dose depending on
gentamicin level as shown in table below.
Gentamicin
Multiple daily dosing
Ideal range
(other than Streptococcal &
Staphylococcal endocarditis)
Streptococcal &
Staphylococcal endocarditis
Level too high
Level too low
Pre-dose (mg/L)
Prior to next dose
<2
Post-dose (mg/L)
1hr after last dose
5 – 10
<1
3–5
Reduce frequency
Reduce dose
Increase dose
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 19 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Adult Antibiotic Guidelines Secondary Care
Owner: Antibiotic Working Group
ABHB/Clinical/0008
Vancomycin
These dosing guidelines are for intra-venous dosing. For information for oral
dosing in the treatment Clostridium difficile, please see section 4.
Intravenous vancomycin: Initially, the size of dose is determined by the
patient’s weight, and the frequency of dosing by the renal function. Doses
should then be adjusted according to serum levels.
Dilute vancomycin in 250mL of 0.9% sodium chloride given over 2 hours.
50–60kg patient: 750mg doses
60–80kg patient: 1g doses
Other weights: 15mg/kg to a max of 2g per dose.
Creatinine
>80
clearance
(mL/min)
Vancomycin every
dosing
12
interval
hours
60-80
every
18
hours
40-60
every
24
hours
30-40
every
36
hours
20-30
every
48
hours
10-20
every
60
hours
<10 or
on
dialysis
every
96
hours
Serum level measurement
Levels are required for every patient before the third dose. If the patient is
renally stable and no adjustments were required after the first level then
assays should be taken every 3 to 5 days. Levels need to be taken more
regularly in renal impairment and in deteriorating patients.
Adjust dose depending on vancomycin level as shown in table below. Peak
levels are not routinely required, but may be performed if there is concern
about clinical response to therapy.
Vancomycin
Ideal range for
uncomplicated infections
Range for Bacteraemia,
Endocarditis, Osteomyelitis,
Pneumonia, less susceptible
(VISA) strains of MRSA
Level too high
Level too low
Pre-dose (mg/L)
Prior to next dose
10 – 15
Post-dose (mg/L)
1hr after last dose
20 – 40
15 – 20
20 – 40
Reduce frequency
Increase frequency
(max 12 hourly)
Reduce dose
Increase dose
Ref: Cardiff and Vale University Health Board. Good Prescribing Guide. Prescribing Guidelines for Medical Staff.
Sixth Edition. January 2011
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 20 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Secondary Care Adult Antibiotic Guidelines
Owner: Antibiotic Working Group
ABHB/Clinical/0008
28. Antimicrobial Prophylaxis Summary Table
Please refer to the full Antimicrobial Prophylaxis Guidelines for further
information.
MRSA – If a patient has been known to have MRSA colonisation or infection
in the past, its pre-operative eradication and the addition of specific antiMRSA prophylaxis is recommended, particularly for major invasive
procedures. This is in addition to the routine prophylactic antibiotics if
they will not themselves cover MRSA. A single dose of Teicoplanin
400mg IV is advised for adults. Vancomycin IV 1g infused over 100 minutes
is a less practical alternative.
It is intended that antibiotic prophylaxis is given as a single dose. Although
there has been a tradition of repeat doses for 24 hours or more for some
procedures, the supporting evidence is weak and this is no longer
recommended in all but the most exceptional circumstances. If during the
procedure it is apparent that there is infection at the operative site, it is
appropriate to extend the prophylactic dose into a therapeutic course of an
antibiotic.
An additional dose of the prophylactic agent intra-operatively or postoperatively is not indicated in adults unless the procedure lasts for more than
4 hours, or there is blood loss of 1500mL during surgery or haemodilution of
up to 15mL/kg. Post-operative doses of antibiotic for prophylaxis should not
otherwise be given for any operation. Any decision to prolong prophylaxis
beyond a single dose should be explicit and supported by an evidence base.
If patients have contra-indications to any of the recommended
antibiotics, please contact microbiology.
Procedure
Upper GI – Oesophageal,
Gastric, Duodenal
Uncomplicated Small bowel
Appendicectomy
Colo-rectal
Perforated or Gangrenous
Appenicectomy or Colo-rectal
Biliary – laparoscopic
cholecystectomy
Biliary – Open but
uncomplicated
Biliary – Open procedure,
Complicated / Infected
ERCP – Endoscopic
Retrograde Cholangiopancreatography
Breast
First line
Gentamicin 120mg IV
Alternative
Gentamicin 120mg IV &
Metronidazole 500mg IV
Gentamicin 120mg IV &
Metronidazole 500mg IV
Nil, unless converted to
open procedure
Gentamicin IV 120mg
Gentamicin 120mg IV &
Metronidazole 500mg IV
Gentamicin 120mg IV
Flucloxacillin IV 1g
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 21 of 26
Clindamycin 600mg
IV
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Secondary Care Adult Antibiotic Guidelines
Owner: Antibiotic Working Group
Gynaecology – Hysterectomy
& other procedures involving
vaginal or uterine incision
Caesarean Section
Termination of Pregnancy
ENT – Head and Neck &
Otological Procedures
Hernia repair with mesh (Open
or laparoscopic)
Urology – see also ‘Prostate’
below
Prostate Resection
(Transurethral) TURP
Prostate Biopsy (Transrectal)
Vascular – arterial surgery in
abdomen, pelvis or legs
Orthopaedics – clean
Arthroplasty, Internal fixation of
fractures
Orthopaedics – contaminated
wound, complex open
fractures with extensive tissue
damage
Lower limb amputation or after
major trauma
Closed clean orthopaedic
procedures without prosthesis
Urinary Catheter Change –only
for patients at exceptional risk
– e.g. with prosthetic implants
ABHB/Clinical/0008
Gentamicin 120mg IV &
Metronidazole 500mg IV or
1g PR
Cefuroxime 1.5g IV &
Metronidazole IV 500mg
Metronidazole 400 mg PO
Clarithromycin 500mg IV &
Metronidazole 500mg IV
Amoxicillin 1g IV,
Gentamicin IV 120mg IV,
Metronidazole IV 500mg
Choose cover from preoperative culture result
Clindamycin 600mg
IV
Add treatment for
genital Chlamydia if
not ruled out, e.g.
Doxycycline
Clindamycin 600 mg
IV & Gentamicin 120
mg IV
If results negative
then gentamicin IV
120mg
Gentamicin 120mg IV
Ciprofloxacin 750mg oral &
Metronidazole 400 mg oral
Flucloxacillin 1g IV&
Teicoplanin IV
Gentamicin 120mg IV
400mg
Add Metronidazole if diabetic or gangrene or
amputation
Antibiotic is sometimes also incorporated into
vascular grafts
Teicoplanin 400 mg IV & Gentamicin120mg IV
Antibiotic e.g. Gentamicin may also be incorporated
into cement, etc., if used
Teicoplanin 400 mg IV &
Gentamicin120mg IV &
Metronidazole 500mg IV or
1g PR
Benzyl penicillin 600mg IV
Metronidazole IV
QDS/ Amoxicillin 500mg
400-500mg TDS for
PO TDS for 5 days
5 days
No prophylaxis
recommended
Choose cover from preIf negative then
procedure culture result if
Gentamicin 120mg
available
IV
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 22 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Secondary Care Adult Antibiotic Guidelines
Owner: Antibiotic Working Group
ABHB/Clinical/0008
29. Antimicrobial dosing guidelines in adults with renal impairment and failure
(Doses taken from The Renal Handbook, 3rd edition 2009, UK Renal Pharmacy Group, the Electronic
Medicines Compendium www.emc.medicines.org.uk Summaries of Product Characteristics)
CAPD = Continuous ambulatory peritoneal dialysis
HD = Intermittent Haemodialysis
N/A = Preparation not available or not used routinely within Health Board
Dose for patients on CAPD or HD as per patients with a Creatinine Clearance (CrCl) <10ml/min unless
otherwise stated.
CrCl may be calculated by: (140 – age in years) x body weight (kg) (x1.25 for men) = mL/min
Serum creatinine (micromoles per litre)
If patient is a dialysis patient please contact your ward pharmacist for advice.
Antibiotic
CrCl
(mL per minute)
Oral Dose
Intravenous Dose
Aciclovir
Treatment of
Herpes
Simplex
> 50
25 – 50
10 – 25
< 10
200mg – 400mg 5 x /day2
200mg – 400mg 5 x /day2
200mg 3 – 4x /day
200mg bd
5mg/kg tds3
5mg/kg bd
5mg/kg od
2.5mg/kg od
Aciclovir
Treatment of
Varicella Zoster 1
> 50
25 – 50
10 – 25
800mg 5 x /day
800mg 5 x /day
800mg bd - tds
< 10
400mg – 800mg bd
5-10mg/kg tds3
5-10mg/kg bd3
5-10mg/kg od3
(some units use 3.5-7mg/kg
od)
2.5-5mg/kg od3
> 20
N/A
10 – 20
N/A
< 10
N/A
600mg – 1.2g qds, depending
on severity of infection
Cefalexin
> 20
N/A
Cefotaxime
10 – 20
< 10
> 10
250mg qds or 500mg bd/tds
Recurrent UTI prophylaxis:
125mg at night
500mg bd/tds
250mg – 500mg bd/tds
N/A
< 10
N/A
>10
N/A
<10
N/A
Cefuroxime
>50
20 – 50
10 – 20
<10
N/A
N/A
N/A
N/A
750mg – 1.5g tds
750mg – 1.5g tds
750mg – 1.5g bd / tds
750mg – 1.5g od/bd
Ciprofloxacin
>20
10 – 20
<10
CAPD /HD
250mg – 750mg bd
50% - 100% of normal dose
50% of normal dose
250mg bd
Up to 500mg bd in CAPD
peritonitis
100mg – 400mg bd
50% – 100% of normal dose
50% of normal dose
200mg bd
Clarithromycin
>30
<30
250mg – 500mg bd
250mg – 500mg bd
500mg bd
250mg – 500mg bd
Benzylpenicillin
Note: Higher
doses (>7.2g/day)
should be
reserved for the
treatment of
meningitis and
severe cellulitis
Ceftriaxone
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 23 of 26
2.4g – 14.4g daily in 4 – 6
divided doses.
600mg – 2.4g qds, depending
on severity of infection
N/A
N/A
Mild infection: 1g bd
Moderate infection: 1g tds
Severe infection: 2g qds
Life-threatening infection: up
to 12g daily in 3 – 4 divided
doses.
1g bd / tds
1g od;
2 – 4g daily in severe
infections
Dose as in normal renal
function, maximum 2g daily
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Secondary Care Adult Antibiotic Guidelines
Owner: Antibiotic Working Group
ABHB/Clinical/0008
Antibiotic
CrCl
(mL per minute)
Oral Dose
Intravenous Dose
Co-amoxiclav
>30
375mg – 625mg tds
1.2g tds.
Up to qds in severe infections
10 – 30
Dose as in normal renal
function
Dose as in normal renal
function
1.2g bd
<10
1.2g stat followed by either
600mg tds or 1.2g bd
Co-trimoxazole
(N.B. Higher
doses used for
Pneumocystis)
>30
15 – 30
<15
960mg od for SBP prophylaxis
480mg od for SBP prophylaxis
480mg od for SBP prophylaxis
Doripenem
>50
30 – 50
<30
N/A
N/A
N/A
500mg tds
250mg tds
250mg bd
Ertapenem
>30
10 – 30
<10
N/A
N/A
N/A
1g od
Use 50% – 100 % of dose
Use 50% of dose or 1g three
times per week
Erythromycin
>10
250mg – 500mg qds or
500mg – 1g bd
<10
50% – 75% of normal dose,
maximum 2g daily
Mild to moderate infection,
25mg/kg/day.
Severe infection or
immunocompromised,
50mg/kg/day (maximum
4g/day for adults)
50% – 75% of normal dose,
maximum 2g/day
>10
250mg – 1g qds
<10
Dose as in normal renal
function. Maximum dose is 4g
daily
>70
N/A
31 – 70
21 – 30
<20
N/A
N/A
N/A
CAPD/HD
N/A
>70
30 – 70
10 – 30
5 – 10
N/A
N/A
N/A
N/A
CAPD
N/A
HD
N/A
>50
20 – 50
500mg od/bd
Initial dose 250mg – 500mg
then reduce dose by 50%
Initial dose 250mg – 500mg
then 125mg 12 – 24 hourly
Initial dose 250mg – 500mg
then 125mg 24 – 48 hourly
Flucloxacillin
Imipenem /
cilastatin
Gentamicin
Levofloxacin
10 – 20
<10
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 24 of 26
250mg – 2g qds.
Endocarditis: Maximum 2g
every 4 hours (if weight
>85kg)
Osteomyelitis: 8g/day in
divided doses
Dose as in normal renal
function. Maximum dose is 4g
daily
500mg/500mg – 1g/1g tds /
qds (Max 4g/4g per day)
500mg/500mg tds – qds
500mg/500mg bd – tds
250mg/250mg – 500mg/500mg
bd or 3.5mg/3.5mg per kg bd,
whichever is lower
250mg/250mg – 500mg/500mg
bd or 3.5mg/3.5mg per kg bd,
whichever is lower
5mg/kg od. Monitor levels.
3-5mg/kg od. Monitor levels.
2-3mg/kg od. Monitor levels.
2mg/kg every 48 – 72 hours
according to levels.
2mg/kg every 48 – 72 hours
according to levels.
2mg/kg every 48 – 72 hours
according to levels. Dose
after dialysis.
500mg od/bd
Initial dose 250mg – 500mg
then reduce dose by 50%
Initial dose 250mg – 500mg
then 125mg 12 – 24 hourly
Initial dose 250mg – 500mg
then 125mg 24 – 48 hourly
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Secondary Care Adult Antibiotic Guidelines
Owner: Antibiotic Working Group
ABHB/Clinical/0008
Antibiotic
Cr Cl
(mL per minute)
Oral Dose
Intravenous Dose
Meropenem
>50
N/A
20 – 50
10 – 20
<10
N/A
N/A
N/A
500mg – 1g tds, up to 2g tds in
meningitis / cystic fibrosis /
endocarditis
500mg – 2g bd
500mg – 1g bd or 500mg tds
500mg – 1g od
>50
50mg – 100mg qds (or once
nightly for prophylaxis)
50mg – 100mg qds (or once
nightly for prophylaxis)
Use with caution
Contra-indicated: drug
ineffective due to reaching
inadequate urine conc. Toxic
plasma concentrations can
occur with adverse effects.
Nitrofurantoin
20 – 50
<20 and CAPD/HD
Piperacillin /
Tazobactam
Rifampicin
Teicoplanin
Vancomycin
N/A
N/A
N/A
>20
N/A
10 – 20
<10
N/A
N/A
4.5g tds (qds for neutropenic
sepsis)
4.5g bd/tds
4.5g bd
>10
<10
600mg – 1200mg daily in
divided doses
50-100% of normal dose
600mg – 1200mg daily in
divided doses
50-100% of normal dose
>20
N/A
Initially 400mg 12 hourly for 3
doses then subsequently
400mg od
10 – 20
N/A
<10
N/A
Give normal loading dose then
200mg – 400mg every 24 – 48
hours
Give normal loading dose then
200mg – 400mg every 48 – 72
hours
>50
125mg – 500mg qds
depending on severity of
1g bd. Take levels.
20 – 50
Dose as in normal renal
function
Dose as in normal renal
function
Dose as in normal renal
function
500mg – 1g od/bd. Take
levels.
500mg – 1g every 24 – 48
hours based on levels.
500mg – 1g every 48 – 96
hours based on levels.
Clostridium difficile
10 – 20
<10
Drugs that do not usually require dose adjustments include:
Amoxicillin4
Doxycycline
Moxifloxacin
Tigecycline
Azithromycin
Linezolid4
Penicillin V
Trimethoprim
Clindamycin4
Metronidazole
Sodium fusidate
For drugs not listed please contact your Ward Pharmacist.
1
2
3
4
Where a dosage range is given the higher dose should be reserved for severely
immunocompromised patients. These patients may require much higher doses than those
quoted.
For prophylaxis of Herpes Simplex reduce dosing frequency to four times daily.
Treatment of Herpes Simplex Encephalitis – use IV dose at higher range (10mg/kg) quoted.
Contact ward pharmacist if CrCl < 10mL/min or patient is on dialysis.
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 25 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Secondary Care Adult Antibiotic Guidelines
Owner: Antibiotic Working Group
ABHB/Clinical/0008
30. Guidelines for ONCE daily gentamicin administration in adults
Exclusion criteria for once daily dosing is
severe renal impairment, pregnancy and
post-partum women, endocarditis, dialysis,
ascites, cystic fibrosis and major burns
(more than 20% of body).
Affix patient’s
addressograph
here
Ward:_______________________________
Diagnosis:___________________________
Actual Body Weight:___________________
Height:______________________________
REMEMBER TO WRITE GENTAMICIN ON PATIENT’S REGULAR DRUG
CHART WITH ‘SEE GENTAMICIN CHART’ ALONG SIDE.
Dose: In patients with normal renal function give 5mg/kg Ideal Body Weight (maximum of
560mg) to the nearest 40mg increment.
(Neutropenic policy exempt: states 6mg/kg od)
To calculate a patient’s ideal body weight:
Males:
IBW = 50kg + 0.9kg for every cm over 152cm
Females:
IBW = 45.5kg + 0.9kg for every cm over 152cm
If patient’s actual body weight is 30% more than IBW:
Adjusted body weight = IBW + 0.4(Actual body weight – IBW)
For patients with renal impairment contact microbiology or medicines information.
Administration:
The daily dose should be diluted in 100mL sodium chloride 0.9% or glucose 5% and administered over 60 minutes.
Do not wait for level results before administering the next dose if patient has normal renal function.
Date
Serum
Creatinine
Time
gentamicin
given
Nurse’s
signature for
administration
Time
blood
taken
for
level*
1
2
3
4
5
6
7
*Levels:
Next
gentamicin
dose due
in 24
unless
doctor has
otherwise
specified
Gentamicin
level
(mg/L).
When next
dose due.
Signature
All levels should be taken prior to next dose (pre-dose levels). Peak dose levels are not required
First level should be taken prior to the third dose unless the patient is acutely unwell where the level may need to
be taken sooner.
Sample creatinine should be checked every other day and increase frequency of levels if renal function worsens.
If patient is renally stable and the dose was not altered after the 3rd dose then assay every 5-7 days.
Adjust dose depending on gentamicin level as shown in table below .
Ideal range
Level too high
Pre-dose (mg/L)
(Trough level)
<1
Reduce frequency
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 26 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016
Aneurin Bevan Health Board
Secondary Care Adult Antibiotic Guidelines
Owner: Antibiotic Working Group
ABHB/Clinical/0008
Guidelines for MULTIPLE daily gentamicin administration in adults
U
Exclusion criteria for once daily dosing is
severe renal impairment, pregnancy and
post-partum women, endocarditis, dialysis,
ascites, cystic fibrosis and major burns
(more than (20% of body).
Affix patient’s
addressograph
here
Ward:_______________________________
Diagnosis:___________________________
Actual Body Weight:___________________
Height:______________________________
REMEMBER TO WRITE GENTAMICIN ON PATIENT’S REGULAR DRUG
CHART WITH ‘SEE GENTAMICIN CHART’ ALONG SIDE.
Dose: 3 to 5mg/kg Ideal Body Weight per day in divided doses, every 8 or 12 hours.
Usually 120mg loading dose, then 80mg or 120mg every 8 to 12 hours.
Dose to the nearest 40mg increment.
To calculate a patient’s ideal body weight:
Males:
IBW = 50kg + 0.9kg for every cm over 152cm
Females:
IBW = 45.5kg + 0.9kg for every cm over 152cm
If patient’s actual body weight is 30% more than IBW:
Adjusted body weight = IBW + 0.4(Actual body weight – IBW)
For patients with renal impairment contact microbiology or medicines information.
Administration:
The daily dose should be diluted with 50-100mL sodium chloride 0.9% or glucose 5% and administered over 20-30
minutes. Do not wait for level results before administering the next dose if patient has normal renal function.
Day
Date & time dose
to be given
(00:00hrs)
Actual time
given
(00:00hrs)
Nurse’s signature of
administration
Time level
taken
Gentamicin
levels mg/L
Pre
Pre
Post
Reviewed by doctor/
pharmacist
Post
1
2
3
4
5
6
Levels will need to be taken more regularly in renal impairment or deteriorating patients. If patient is renally stable
and no adjustments were required after the first levels (at the third dose), assays should be taken every 3-5 days.
Adjust dose depending on gentamicin level as shown in table below.
Ideal range (other than Streptococcal or
Staphylococcal endocarditis)
Streptococcal or Staphylococcal endocarditis
Level too high
Level too low
Pre-dose (mg/L)
Prior to next dose
<2
Post-dose (mg/L)
1hr after last dose
5-10
<1
Reduce frequency
3-5
Reduce dose
Increase dose
Status: Issue 3
Approved by: Clinical Standards & Policy Group
Page 27 of 26
Issue date: 4 March 2013
Review by date: 4 March 2016