Download Antibiotic Guidelines - West Suffolk NHS Foundation Trust

CLINICAL GUIDELINE
CG10118-5
Antibiotic Guidelines
For use in (clinical areas):
All clinical areas
For use by (staff groups):
All clinicians
For use for (patients):
For use for all patients
Document owner:
Consultant Microbiologists
Status:
Approved
Purpose of the Guideline
This document provides comprehensive guidelines concerning the use of empiric antibiotics to
treat commonly encountered infections.
National guidance and local sensitivity/resistance patterns are taken into account.
The guideline is intended to help clinicians provide the best treatment, reduce the incidence of
side effects, prevent the emergence of antibiotic resistant organisms, and reduce the incidence of
Clostridium difficile associated diarrhoea1,2.
Guidelines covering antibiotic prophylaxis for surgical procedures are found in CG10049.
Contents
1. INTRODUCTION
2. TABLE OF EMPIRIC ANTIBIOTIC THERAPY
3. ANTIBIOTIC COURSES: DURATION AND ROUTE OF ADMINISTRATION
3.1. Intravenous to oral switch
4. ALLERGIES
4.1. Penicillin allergy
5. ANTIBIOTIC ASSAYS
5.1. Once daily gentamicin protocol for adults with sepsis
5.2. Other gentamicin dosing regimes
5.3. Vancomycin dosing
5.4. Estimating creatinine clearance
6. ANTIBIOTIC GUIDELINES FOR PATIENTS REQUIRING CRITICAL CARE
7. DEVELOPMENT OF THIS GUIDELINE
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 1 of 24
West Suffolk Hospital NHS Trust
CG10118-5
Antibiotic Guidelines
1. INTRODUCTION
These guidelines are empiric, to be used at the start of treatment. Doses mentioned are for adults
unless otherwise specified and assume normal renal and hepatic function.
Antibiotics are NOT harmless. Serious side effects include Clostridium difficile diarrhoea, which
may be fatal. Inappropriate antibiotic use leads to the development of resistant strains of bacteria.
Principles of antibiotic prescribing
Before using any antibiotic it is essential to determine whether it is 1) necessary and 2)
appropriate.
The clinical indication for antibiotics must be stated on the drug chart and in the medical
notes. (Note: this may need updating as the clinical picture progresses).
All antibiotic therapy must be reviewed on a daily basis, to ensure it remains appropriate to
continue, taking account of culture and sensitivity results, clinical response and microbiological
advice.
Most conditions do not require more than 7 days antibiotic treatment and may need less.
Course length should be documented on the drug chart and in the notes.
Narrow-spectrum antibiotics should replace empirical broad-spectrum antibiotics at the
earliest opportunity and in conjunction with microbiology results.
Oral antibiotics should be given in place of IV antibiotics within 72 hours at the latest,
EXCEPT in the following circumstances or on Consultant Microbiologist advice:
Meningitis
Endocarditis
Continuing sepsis:
i.e: 2 or more of: temperature >38°c or <36°c
Necrotising fasciitis
heart rate >90 beats/min
Acute osteomyelitis
respiratory rate >20/min
Septic arthritis
WBC count <4 or >12 x 109 /L
Epidural abscess
Critical care patients
Discitis
Paediatric patients
Epiglottitis
Nil by mouth / not absorbing
Febrile neutropenia
No suitable oral antibiotic available
Nursing staff have been instructed not to administer IV antibiotics beyond 72 hours
UNLESS the patient’s consultant has documented reasons for this in the patient’s notes or
a valid condition, as above, is recorded on the drug chart. The team will be asked to review
any IV antibiotic prescriptions that do not fit these criteria as a matter of urgency.
This will require appropriate review & planning by the team ahead of weekends and bank holiday
periods.
This practice will be audited.
Where this practice is not followed appropriately an incident form will be submitted.
Source: consultant microbiologistsConsultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 2 of 24
West Suffolk Hospital NHS Trust
CG10118-5
Antibiotic Guidelines
Certain antibiotics are only available on recommendation from a consultant microbiologist,
or for specified infections.
These include:
2nd and 3rd generation cephalosporins
quinolones e.g. ciprofloxacin
carbapenems e.g. meropenem & ertapenem
tigecycline
daptomycin
clindamycin
systemic antivirals and antifungals.
Guidance on taking specimens can be found in the Pathology Services Handbook.
Remember that some antibiotics have significant interactions with other medication e.g.
warfarin, cyclosporin, methotrexate, oral contraceptives etc. Please refer to the BNF for
information.
2. TABLE OF EMPIRIC ANTIBIOTIC THERAPY
The following table outlines suitable antibiotic treatment for a range of commonly encountered
clinical conditions.
Always consider first line treatments. Only substitute these with second line treatments if the
patient is allergic or has failed to respond to first line treatment.
For septicaemic patients, consider the likely source and prescribe according to the table. See also
section 6 – guidelines for critical care patients.
For haematology and oncology patients, see also: Treatment of febrile/septic neutropaenic
patients: CG10066-5
Treatment of febrile non-neutropaenic patients
CG10070-5
Antifungal therapy: CG10061-2
Neutropaenic prophylaxis: CG10087-2
PCP prophylaxis: CG10083-2
If in doubt, please contact the consultant microbiologists (available 24 hours a day, 7 days a week
via the hospital switchboard).
Source: consultant microbiologistsConsultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 3 of 24
West Suffolk Hospital NHS Trust
Table 1
INFECTION
CG10118-5
Antibiotic Guidelines
Empiric antibiotic treatment for common infections in adults
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
COMMENTS
RESPIRATORY TRACT INFECTIONS
Tonsillitis/Quinsy
Oral penicillin V 500mg q.d.s. or
i.v. benzyl penicillin 1.2g q.d.s.
for 10 days
Epiglottitis
Ceftriaxone 2g od IV
Oral Clarithromycin 250mg b.d.
or i.v. clarithromycin 500mg b.d.
If anaerobic infection including
Lemierre’s disease
(Fusobacterium necrophorum
suppurative thrombophlebitis) or
Ludwig’s angina suspected, add
metronidazole 400mg t.d.s.
Discuss with microbiologists
Sinusitis
Acute
Oral Co-amoxiclav 625mg t.d.s.
Oral Clarithromycin 250mg b.d.
Chronic
Oral doxycycline 200mg (day 1)
then 100mg o.d.(days 2 to 7)
Oral Clarithromycin 250mg b.d.
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
i.v. treatment with 1.2g coamoxiclav t.d.s. or clarithromycin
500mg b.d. may be given if
required – change to oral
treatment as soon as possible
Add oral metronidazole 400mg
t.d.s. if anaerobes suspected.
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CG10118-5
Antibiotic Guidelines
INFECTION
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
COMMENTS
Acute otitis media
Oral Co-amoxiclav 625mg t.d.s.
Oral Clarithromycin 250mg b.d.
If recurrent, consider anaerobes.
Infective exacerbation COPD
Oral doxycycline 200mg (day 1)
then 100mg o.d.(days 2 to 7)
Oral clarithromycin 250 b.d. for 7
days
Send sputum for culture.
(no signs of pneumonia on CXR,
purulent sputum)
Severe infective exacerbation
COPD (incl. Bronchiectasis)
Oral clarithromycin 500mg b.d.
If severe, piperacillin/tazobactam
4.5g t.d.s. + gentamicin
Failed antibiotic therapy –
discuss with microbiologists
Send sputum.
Discuss with microbiologists
(no signs of pneumonia, purulent
sputum, pH <7.35)
Community acquired pneumonia
Mild (CURB 65 = 0-2)
N.B. need for frequent review to
identify deterioration
Severe (CURB 65 ≥ 3)
C - Confusion
Oral clarithromycin 500mg b.d.
for 7 days
U - Urea >7mmols/l
R - Resp ≥ 30/min
i.v. clarithromycin 500mg b.d. +
i.v. benzyl penicillin 1.2g q.d.s.
Switch to oral clarithromycin
500mg b.d. at 2 days unless no
improvement
Source: Consultant Microbiologists
Status: Approved
Oral amoxycillin 500mg tds Only
following consultant advice
Issue date: May 2009
Valid until: February 2012
B - BP diastolic <60mmHg
No response to 1st line or
probable aspiration consider
Age > 65 years
piperacillin/tazobactam 4.5g t.d.s.
to cover gram negatives
(score 1 point for each of the
above)
Penicillin allergy – discuss with
microbiologists
Risk of atypical infection e.g.
Legionella, psittacosis – discuss
with microbiologists
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CG10118-5
Antibiotic Guidelines
INFECTION
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
COMMENTS
Post-influenzal pneumonia
i.v. flucloxacillin 2g qds + i.v.
gentamicin 5mg/kg once daily
(monitor according to gentamicin
guidelines)
Penicillin allergy – discuss with
microbiologists
Discuss with microbiologists
Document clinical findings
Hospital acquired chest
infection(>3 days from admission)
Sputum for culture
No evidence of consolidation on
CXR
Oral doxycycline 200mg (day 1)
then 100mg o.d.(days 2 to 7)
Evidence of new consolidation on
CXR
i.v. piperacillin/tazobactam 4.5g
t.d.s. (+ i.v. gentamicin 5mg/kg
o.d. if severe) for 5-7 days.
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Blood cultures if pyrexial
Penicillin allergy – discuss with
microbiologists.
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INFECTION
CG10118-5
Antibiotic Guidelines
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
COMMENTS
URINARY TRACT INFECTIONS
ESBL INFECTIONS
Always discuss with microbiologists prior to commencing treatment
Trimethoprim 200mg b.d. orally
Uncomplicated UTI
Asymptomatic bacteriuria
Nitrofurantoin 50mg 6 hourly
Do not treat even if >65 yrs or diabetic unless pre-op.
Age >40, otherwise well
Source: Consultant Microbiologists
Status: Approved
3 day course adequate for most
adults.
Only treat if pregnant or before
instrumentation or surgery.
Treat according to culture results.
Send MSU & blood cultures
prior to starting empiric
antibiotics.
Acute pyelonephritis /
complicated urosepsis
Age <40, otherwise well
Send mid-stream or clean
catch urine sample for culture.
Await results if no systemic
symptoms and treat according to
results.
Co-amoxyclav 1.2g tds i.v
Piperacillin/tazobactam
4.5g tds iv
Issue date: May 2009
Valid until: February 2012
i.v. gentamicin 5mg/kg o.d.
Review with culture results at 48
hours and switch to oral if
possible – see table 2, section
3.1
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CG10118-5
Antibiotic Guidelines
INFECTION
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
Catheter associated bacteriuria
Antibiotics do not eradicate bacteria from urinary catheters.
COMMENTS
Results of dipstick testing are not helpful in diagnosing catheter related infections – send a CSU if
systemically unwell, or pre-operatively. Treat according to culture report. Consider change or removal of
catheter.
If in doubt, discuss with microbiologists
GENITAL TRACT INFECTIONS
Prostatitis/epididymo-orchitis
oral ofloxacin 400mg b.d. for 28
days
Pelvic inflammatory disease
Oral metronidazole 400mg t.d.s.
+ oral ofloxacin 400mg bd for 14
days
oral doxycycline 200mg on day 1
then 100mg b.d. for a total of 28
days
Oral doxycycline 100mg b.d. +
oral metronidazole 400mg
t.d.s.for 14 days
Refer to GUM if a sexuallytransmitted infection is suspected
Or
Oral erythromycin 500mg b.d. +
metronidazole 400mg t.d.s. for 14
days.
Genital chlamydiosis
Vaginal candidiasis
Source: Consultant Microbiologists
Status: Approved
Refer to GU Medicine
Clotrimazole pessary 500mg stat
Issue date: May 2009
Valid until: February 2012
Oral fluconazole 150 mg stat
Alternative topical preparations
available if no response – discuss
with microbiologists.
Page 8 of 24
West Suffolk Hospital NHS Trust
INFECTION
CG10118-5
Antibiotic Guidelines
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
COMMENTS
Antibiotics not usually indicated
Severe campylobacter infections
– oral clarithromycin 250mg b.d.
for 5-7 days (but check
sensitivities as some are
resistant)
Patient to be admitted to side
room. Notify Infection Control/oncall microbiologist
GASTROINTESTINAL INFECTIONS
Community acquired
gastroenteritis
Send faeces for culture
Bacteraemic infections may
require antibiotic therapy –
discuss with microbiologists
Helicobacter pylori
Source: Consultant Microbiologists
Status: Approved
Amoxycillin 1g bd
Lansoprazole 30mg bd
Clarithromycin 500mg bd
Metronidazole 400mg bd
Lansoprazole 30mg bd
Clarithromycin 250mg bd
All 7 days
All 7 days
Issue date: May 2009
Valid until: February 2012
Page 9 of 24
West Suffolk Hospital NHS Trust
INFECTION
CG10118-5
Antibiotic Guidelines
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
COMMENTS
Clostridium difficile
Review drug chart.
Only treat if symptomatic –
diarrhoea with green, foul smelling
stool with history of antibiotic use
Stop antibiotics where possible
Mild may respond to stopping
concurrent antibiotic treatment.
Oral metronidazole 400mg t.d.s.
for 10 days
Oral vancomycin 125mg qds for
10 days if failed to respond to
metronidazole
Severe
Fever, leucocytosis, sepsis,
hypoalbuminaemia, abdominal
tenderness/distension
If pseudo membranous colitis
suspected commence oral and i.v.
vancomycin and get URGENT
SURGICAL REVIEW
Oral vancomycin 125-500 mg qds
for 10-14 days – discuss with
microbiologists
DISCUSS WITH
MICROBIOLOGISTS
Pancreatic and biliary sepsis
Severe intra-abdominal sepsis
i.v. Piperacillin/tazobactam 4.5g
t.d.s.
Add i.v. gentamicin 5mg/kg if
severe
i.v. Piperacillin/tazobactam 4.5g
t.d.s.
Discuss with microbiologists
Discuss with microbiologists
Add i.v. gentamicin 5mg/kg if
severe
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 10 of 24
West Suffolk Hospital NHS Trust
INFECTION
CG10118-5
Antibiotic Guidelines
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
COMMENTS
CARDIOVASCULAR SYSTEM
Bacterial endocarditis
Take 3 sets of blood cultures and discuss URGENTLY with microbiologists
CENTRAL NERVOUS SYTEM
Bacterial meningitis
i.v. Ceftriaxone 2g b.d. for 10-14
days (discuss with micro)
Immunocompromised – add i.v.
amoxycillin 2g q.d.s. to cover
Listeria
Always discuss with
microbiologists.
Send CSF for microscopy and
culture only if safe to do so.
Penicillin allergy Chloramphenicol 25 mg/ Kg
6hrly IV
Take blood cultures.
IV clarithromycin 500mg bd or
vancomycin 1g bd
Oral flucloxacillin if not severe. If
severe (e.g. necrotising fasciitis,
burns) discuss with
microbiologists. If MRSA D/W
microbiologists.
Consider EDTA blood sample for
meningococcal PCR, throat swab
and skin aspirate if ?
meningococcaemia with Rash.
SKIN, SOFT TISSUE, BONE AND JOINT INFECTIONS
Cellulitis
Source: Consultant Microbiologists
Status: Approved
IV benzylpenicillin 1.2 qds & IV
flucloxacillin 2g qds
Issue date: May 2009
Valid until: February 2012
Page 11 of 24
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CG10118-5
Antibiotic Guidelines
INFECTION
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
Chronic leg ulcers
Diabetic ulcers
Bacteria are ALWAYS present. Take diagnostic swabs ONLY if inflamed (i.e. red/hot/increasing pain,
rapid deterioration). Swab from around the inflamed edge, do not take swabs from exudates. Treat
according to culture results.
Take swabs and discuss with microbiologists.
Post-operative wound infection
Send wound swab for culture
Osteomyelitis
i.v. flucloxacillin 2g q.d.s.
Add oral fusidic acid 500mg tds
Discuss with microbiologists,
particularly if MRSA positive.
history of trauma/intervention/
skin lesions
i.v. flucloxacillin 2g q.d.s.
Add oral fusidic acid 500mg tds
Discuss with microbiologists,
particularly if MRSA positive.
community acquired, presumed
haematogenous infection
i.v. ceftriaxone 2g o.d. On
microbiologist advice
Prosthetic joint infection
Discuss with microbiologists
COMMENTS
Discuss with microbiologists
Septic arthritis
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 12 of 24
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CG10118-5
Antibiotic Guidelines
INFECTION
1st LINE ANTIBIOTICS
2nd LINE ANTIBIOTICS
Compound fracture/badly
soiled wounds
Co-amoxiclav 1.2g t.d.s. i.v.
Discuss with microbiologists
Bites (human or animal)
Oral Co-amoxiclav 625mg t.d.s.
Discuss with microbiologists
COMMENTS
Refer to blood borne virus policy
for human bites
MRSA INFECTIONS
Antibiotics not required for colonisation.
If intravenous treatment clinically indicated, commence i.v. vancomycin 1g b.d. and discuss with microbiologists.
If oral treatment required, treat according to the results of laboratory antibiotic susceptibility testing.
N.B. oral vancomycin is NOT absorbed and CANNOT be used to treat MRSA infections.
SEPSIS IN THE IMMUNOCOMPROMISED PATIENT
No central line
Central line in situ
Source: Consultant Microbiologists
Status: Approved
i.v. Piperacillin/tazobactam 4.5g
t.d.s. + gentamicin 5mg/kg o.d.
As above but add i.v. vancomycin
Issue date: May 2009
Valid until: February 2012
Send full septic screen. Contact
relevant specialist (haematologist,
oncologist, GUM physician) and
microbiologist to discuss.
Page 13 of 24
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CG10118-5
Antibiotic Guidelines
3. ANTIBIOTIC COURSES: DURATION AND ROUTE OF ADMINISTRATION
The duration of antibiotic treatment must be stated on the drug chart.
All prescriptions for intravenous antibiotic treatment must be reviewed within 48 hours to
determine whether a change to oral therapy is appropriate.
Where a course length is not stated, ward based pharmacists will contact the prescriber to review
the prescription.
3.1.
INTRAVENOUS TO ORAL SWITCH
For patients on i.v. antibiotics, it is essential that medical staff ensure that oral antibiotic therapy is
introduced as soon as practicable. This is important for patient safety as intravascular devices
are associated with infection including fatal septicaemia.
Please discuss the case with a consultant microbiologist if you think that stepping down is
inappropriate or you are unclear as to the best oral agent to use.
Long courses of i.v. antibiotics are indicated for some infections e.g. endocarditis and some
bone/joint infections. The prescription chart should be annotated to indicate that a long course is
indicated, with a stop or review date added.
Check culture and antibiotic susceptibility results to ensure that the chosen oral antibiotic
is likely to be effective.
See Table 2
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 14 of 24
West Suffolk Hospital NHS Trust
Table 2
CG10118-5
Antibiotic Guidelines
Antibiotic Options when switching from IV to oral treatment
A direct switch can occur where possible e.g. clarithromycin IV Æ clarithromycin PO.
Condition
Firstly,
Secondly, if no positive
microbiology to guide you and
antibiotics need to continue:
Respiratory
COPD
Check & be guided by
microbiology results
Co-amoxiclav but discuss with
microbiologist if Pseudomonas thought
likely.
Refer to section 4.1 if penicillin allergy.
Community-acquired
pneumonia
Check & be guided by
microbiology results
Amoxicillin, co-amoxiclav, clarithromycin,
or doxycycline.
If atypical respiratory pathogen suspected
use clarithromycin or doxycycline.
- Post-influenza
pneumonia
Check & be guided by
microbiology results
Flucloxacillin or clarithromycin.
Hospital-acquired
pneumonia
Check & be guided by
microbiology results
Co-amoxiclav but discuss with
microbiologist if Pseudomonas thought
likely.
Doxycycline if MRSA positive.
Refer to section 4.1 if penicillin allergy.
Urinary Infections
All
Check & be guided by
microbiology results
Gastro-intestinal infections
Pancreatic, biliary &
severe abdominal sepsis
Check & be guided by
microbiology results
Co-amoxiclav.
Refer to section 4.1 if penicillin allergy.
Skin & soft tissue infections
Cellulitis
Check & be guided by
microbiology results
Direct switch e.g. flucloxacillin IV Æ
flucloxacillin PO
If on vancomycin for MRSA use
doxycycline PO.
If on vancomycin for penicillin allergy use
clarithromycin PO and refer to section 4.1.
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 15 of 24
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CG10118-5
Antibiotic Guidelines
4. ALLERGIES
It is important to realise that allergic reactions are responsible for a number of deaths each year in
National Health Service hospitals. To prevent these happening, and to ensure that appropriate
antibiotics are not withheld due to an inaccurate history, medical staff must establish the true
allergy status of each patient.
4.1
PENICILLIN ALLERGY
The most important side-effect of the penicillins is hypersensitivity which causes rashes and
anaphylaxis and can be fatal. Allergic reactions to penicillins occur in 1–10% of exposed
individuals; anaphylactic reactions occur in fewer than 0.05% of treated patients.
Check the history of the reported allergy; it is often inaccurate. Patients commonly report
minor skin reactions and stomach upset as penicillin allergy. There is no test for allergy.
Allergic or anaphylactic response is not dose related.
Individuals with a history of anaphylaxis, urticaria, or rash immediately after penicillin
administration are at risk of immediate hypersensitivity to a penicillin; these individuals
should not receive a penicillin, a cephalosporin or another beta-lactam antibiotic.
Individuals with a history of a minor rash (i.e. non-confluent rash restricted to a small
area of the body) or a rash that occurs more than 72 hours after penicillin
administration are probably not allergic to penicillin but the possibility of an allergic reaction
should be borne in mind.
Cephalosporins and carbapenems should be used with caution in penicillin allergic patients since
there is a quoted incidence of 10% cross-allergenicity.
Substitutes: (where other allergies do not contra-indicate) if uncertain please discuss with a
consultant microbiologist
•
For penicillin use oral clarithromycin or i.v. cefuroxime/ceftriaxone following discussion
with microbiologist
•
For flucloxacillin use i.v. cefuroxime/ceftriaxone following discussion with
microbiologist or oral cefradine or clarithromycin
•
For amoxicillin the substitute is dependent upon the indication. Discuss with consultant
microbiologist.
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 16 of 24
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CG10118-5
Antibiotic Guidelines
Penicillin Allergy
All drug-allergies must be specified on medication charts (with the patient’s reaction)
In TRUE penicillin allergy* ALL penicillins, cephalosporins and other beta-lactam antibiotics should
be avoided
Antibiotics to be avoided in
penicillin allergy
Amoxicillin (in Co-amoxiclav/Augmentin,
Heliclear)
CONTRA
-INDICATED
CAUTION
Avoid if serious
penicillin allergy
(e.g. anaphylaxis /
angioedema).
Use with caution if
non-severe allergy
(e.g. minor rash) only
Ampicillin (in Co-fluampicil/Magnapen)
Benzylpenicillin / Penicillin G
Flucloxacillin (in Co-fluampicil / Magnapen)
Phenoxymethylpenicillin / Penicillin V
Piperacillin (in Tazocin)
Ticarcillin (in Timentin)
Antibiotics to be avoided or
used with caution in penicillin
allergy (not a complete list)
Cephalosporins:
Cefixime, Cefotaxime, Cefradine,
Ceftazidime, Ceftriaxone, Cefuroxime
Other beta-lactam antibiotics:
Aztreonam, Imipenem, Meropenem,
Ertapenem
Antibiotics safe in penicillin
allergy (not a complete list),
CONSIDERED
SAFE
Doxycycline
Tigecycline
Vancomycin
Tobramycin
Clarithromycin
Erythromycin
Sodium Fusidate
Co-trimoxazole
Rifampicin
Metronidazole
Ciprofloxacin
(Oxy)Tetracycline
Gentamicin
Azithromycin
Clindamycin
Linezolid
Trimethoprim
Nitrofurantoin
Ofloxacin
*TRUE penicillin allergy includes anaphylaxis, urticaria or rash immediately after penicillin
administration
In cases of INTOLERANCE to penicillin (e.g. gastrointestinal upset) or a rash occurring >72 hours
after administration, penicillins/related antibiotics should not be withheld unnecessarily in severe
infection but the patient must be monitored closely after administration
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 17 of 24
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CG10118-5
Antibiotic Guidelines
5. ANTIBIOTIC ASSAYS: GENTAMICIN AND VANCOMYCIN
Assays for gentamicin and vancomycin are carried out at specific times each day. Assays will not
be carried out during on-call periods except in exceptional circumstances (see Pathology Services
Handbook)
Other antibiotic assays may rarely be required. These are available by arrangement with
Microbiology.
5.1 ONCE DAILY GENTAMICIN PROTOCOL FOR ADULTS WITH SEPSIS
Once daily gentamicin dosing is used for most patients requiring gentamicin.
Exceptions are listed below.
Patients less than 16 years old
Patients with rapidly changing renal function
Patients receiving a single dose of gentamicin as prophylaxis
Patients who are pregnant or in the immediate post-partum period
Patients receiving dialysis
Patients being treated for endocarditis
Patients with ascites
Patients with severe oedema
Patients with major burns (>20%)
Patients with cystic fibrosis
Patients with renal impairment – if creatinine clearance <20ml per minute, then
discuss with Microbiologist or Ward Pharmacist.
Full details about once-daily gentamicin dosing and monitoring are found in CG10100-2
“Antibiotic Guidelines” available on the intranet.
http://www.wsh.nhs.uk/secure/ThePinkBook/NewGuidelines/Docs/CG101002UseofGentimicinasaOnceDailyDoseinAdults.doc
5.2 OTHER GENTAMICIN DOSING REGIMES
Always discuss alternative dosing regimes with a consultant microbiologist.
Except in cases of severe renal impairment, there is no reason to check the levels within the first
48 hours of starting or stopping treatment or changing the dose.
A pre-dose level taken immediately before the dose and a peak level taken 1 hour after i.m. or
i.v. dose should be sent to the laboratory. Accurate timing of peak and trough levels is essential.
State times on the request form.
Pre-dose levels should be less than 2mg/l (ideally <1mg/l)
Peak levels should be 6-10mg/l (exceptions include some cases of endocarditis – discuss with
microbiologist).
5.3 VANCOMYCIN
Full details about Vancomycin dosing and monitoring are found in “Vancomycin
Prescribing and Monitoring Guideline (Excluding Paediatric Patients)” available on the
intranet.
5.4 ESTIMATING CREATININE CLEARANCE
Please refer to the relevant page on the pharmacy section of the intranet Advice on renal
function and dose changes - estimating creatinine clearance
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
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Antibiotic Guidelines
6. EMPIRIC ANTIBIOTIC GUIDELINES FOR PATIENTS REQUIRING
CRITICAL CARE
6.1 Purpose of the Guideline
These guidelines are solely for use for patients under Critical Care Services.
Serious infections in critical care often require empirical antibiotic treatment prior to microbiological
identification of the infectious organism and before antibiotic sensitivities are known. These
guidelines describe the initial antibiotic treatment of common serious infections in patients
admitted to critical care.
The antibiotics must be reviewed once the results of microbiological tests are available. If there is
uncertainty advice must be sought from the on-call Consultant Microbiologist.
6.2. Contents
Intensive Care Unit antibiotic guidelines for:
•
Respiratory Tract Infections
•
Peritonitis
•
Wound Infections
•
Meningitis
•
Urinary Tract Infections
•
Cellulitis
•
Necrotising Fasciitis
Note that the dose of vancomycin and gentamicin will depend on renal function and should be
given in accordance with guidance on critical care.
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 19 of 24
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Antibiotic Guidelines
6.3 RESPIRATORY TRACT INFECTIONS
6.3.1.Community Acquired Pneumonia
1st Choice1
i.v. benzyl penicillin 1.2g q.d.s.
i.v. clarithromycin 500mg b.d.
2nd Choice
i.v. piperacillin/tazobactam 4.5g
t.d.s.
i.v. clarithromycin 500mg b.d.
Major Penicillin
allergy
i.v./oral ciprofloxacin 200/250mg
b.d. plus i.v. vancomycin 1g b.d.
Possible
Aspiration
i.v. piperacillin/tazobactam 4.5g
t.d.s.
If possible
MRSA or PVL
Staph aureus
Add i.v. linezolid 600mg b.d. + i.v.
clindamycin 1.2g b.d. Discuss with
microbiologist
Likely organisms
1. Strep pneumoniae
2. Mycoplasma
3. Haemophilus influenzae
4. Chlamydia
5. Legionella
1. If there is strong history suggestive of influenza, add flucloxacillin 2g iv qds
•
Take urine sample for Legionella antigen and serum sample for atypical organism and viral
serology.
•
Remember to take blood and sputum cultures.
6.3.2. Exacerbation of COAD
1st Choice
As for community acquired
pneumonia (6.3.1 above)
Recently treated
with doxycycline,
penicillin or
cephalosporin?
Discuss with microbiologist
Likely organisms
1. Above +
2. Coliform
3. Pseudomonas
6.3.3. Hospital Acquired Pneumonia
Likely organisms
1 Pseudomonas
2 Coliforms
3 MRSA
4 Anaerobes
1st Choice
i.v. piperaciliin/tazobactam 4.5g
t.d.s. plus i.v. gentamicin
2nd Choice
If penicillin allergic, i.v.
ciprofloxacin 200mg b.d. plus i.v.
vancomycin
Possible
Aspiration
As above (piperacillin/tazobactam
has good activity against
anaerobes). Penicillin allergy – add
metronidazole
Add gentamicin if known Pseudomonas aeruginosa.
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 20 of 24
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CG10118-5
Antibiotic Guidelines
6.3.4. Upper Respiratory Tract Infections
(Epiglottitis, Ludwig’s Angina, Quinsy)
1st Choice
i.v. ceftriaxone 2 g o.d. plus i.v.
metronidazole 500mg t.d.s.
2nd Choice
i.v. vancomycin plus i.v.
ciprofloxacin 200mg b.d.
Likely organisms
1 Strep pneumoniae
2 Strep group A
3 Staph aureus
4 Anaerobes
6.4 Peritonitis
1st Choice
i.v. piperaciliin/tazobactam 4.5g t.d.s.
± i.v. gentamicin
2nd Choice
i.v. tigecycline 100mg first dose then
50 mg b.d. plus i.v. gentamicin
Likely organisms
1 Coliforms
2 Bacteroides
3 Enterococci
4 Pseudomonas
6.5 Wound Infections
6.5.1.Orthopaedic Trauma wounds
1st Choice
i.v. co-amoxyclav 1.2g t.d.s.
2nd Choice
(penicillin
allergy)
i.v. vancomycin plus i.v./oral
ciprofloxacin 200mg/250mg b.d. plus
i.v. metronidazole 500mg t.d.s. (if
soiled)
Likely organisms
1. Staph aureus
2. Streptococcus A
3. Coliform
4. Pseudomonas
5. Anaerobes in dirty
wounds
DO NOT FORGET TETANUS PROPHYLAXIS
6.5.2 Burns & Toxic epidermal necrolysis ( TEN)
1st Choice
i.v. piperaciliin/tazobactam 4.5g t.d.s.
plus i.v. vancomycin
2nd Choice
(penicillin
allergy)
i.v. ciprofloxacin 200mg b.d. plus i.v.
vancomycin1g b.d. plus i.v.
metronidazole 500mg t.d.s.
Source: Consultant Microbiologists
Status: Approved
Likely organisms
1. Staph aureus
2. Streptococcus A
3. Coliform
4. Pseudomonas
5. Anaerobes in dirty
wounds
Issue date: May 2009
Valid until: February 2012
Page 21 of 24
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Antibiotic Guidelines
6.5.3. General Surgery/Gynaecological wound infections
1st Choice*
i.v. flucloxacillin 2g q.d.s. plus i.v.
metronidazole 500mg t.d.s. plus i.v.
gentamicin
2nd Choice
i.v. tigecycline 100mg first dose then
50 mg b.d. plus i.v. gentamicin
Likely organisms
1. Above +
2. Bacteroides
3. Other haemolytic
streptococci
* substitute vancomycin for flucloxacillin if high risk of MRSA or MRSA carrier
6.6 Meningitis
Discuss ALL cases with duty Microbiologist
1st Choice
Ceftriaxone 2g bd iv
2nd Choice
Chloramphenicol 25mg/kg qds iv
Likely organisms
1. N meningitidis
2. Strep pneumoniae
3. H. Influenzae
Patients may have already received benzylpenicillin
Consider acyclovir in suspected viral meningitis
Consider amoxicillin 2g tds iv if Listeria suspected, eg pregnant or immuno-compromised patient
6.7 Urinary Tract Infections
6.7.1. Community acquired UTI
1st Choice
i.v. co-amoxyclav 1.2g t.d.s. ± i.v.
gentamicin
2nd Choice
Discuss with microbiologist
Likely organisms
1. Coliform
2. Staphs and Streps
post-instumentation
6.7.2. Risk of Hospital Acquired UTI
1st Choice
i.v. piperaciliin/tazobactam 4.5g t.d.s.
plus i.v. vancomycin
2nd Choice
Discuss with microbiologist
6.7.3. Risk of ESBL coliform UTI
1st Choice
Meropenem 500mg iv tds or
Ertapenem 1g od iv
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 22 of 24
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CG10118-5
Antibiotic Guidelines
6.8 Cellulitis
Clinical Notes
Always look for an entry site and consider surgical opinion
•
Use vancomycin if high risk of MRSA or MRSA carrier
•
If immunocompromised or diabetic add i.v. piperaciliin/tazobactam 4.5g t.d.s.
•
If trauma or bite add in i.v. metronidazole 500mg t.d.s.
1st Choice
Benzylpenicillin 2.4g 4 hourly and
Flucloxacilin 2g iv qds
2nd Choice
Vancomycin 1g bd iv
Likely organisms
1. Staph aureus
2. Streptococcus
3. Bacteroides
6.9. Necrotising Fasciitis
Obtain an immediate senior surgical opinion
Discuss ALL cases with microbiologist
1st Choice
i.v. ceftriaxone 2g b.d. plus i.v.
gentamicin plus i.v. clindamycin 6001200mg b.d.
2nd Choice
i.v. vancomycin 1g b.d. plus i.v.
piperaciliin/tazobactam 4.5g t.d.s. plus
i.v. clindamycin 600-1200mg bd
Likely organisms
1. Streptococcus A
2. Enterobacteriaciae
3. Bacteroides
4. PVL Staph aureus
References:
1. Wilcox MH et al. Long-term surveillance of cefotaxime and piperacillin-tazobactam prescribing
and incidence of Clostridium difficile diarrhoea. Journal of Antimicrobial Chemotherapy 54
(1):168-72, 2004.
2. O’Connor KA et al. Antibiotic prescribing policy and Clostridium difficile diarrhoea. Quarterly
Journal of Medicine 97 (7):423-9, 2004.
3. Claxton A et al. Restrictive empirical antibiotic guidelines for common infections in HUH
medical admissions and inpatients. Homerton University Hospital NHS Trust. October 2006.
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 23 of 24
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Antibiotic Guidelines
7. DEVELOPMENT OF THE GUIDELINE
Changes compared to previous document
This guideline replaces CG10118-4, issued in March 2008.
Statement of clinical evidence
See references above.
Contributors and peer review
The original guideline was written by the then Chief Pharmacist, John Anthistle, in collaboration
with the consultant microbiologists, Dr Wright and Dr Tremlett.
The changes in this fifth edition have been reviewed by the Chief Pharmacist, Simon Whitworth,
and the consultant microbiologists Dr R. Tilley & Dr C. Barker.
The section on treatment in Critical Care was originally contributed by Dr. N. Levy and Dr. A.
Burns, with amendments for the subsequent editions by the consultant microbiologists.
Distribution list/dissemination method
These guidelines are available to all Trust staff in the electronic clinical guidelines (Pink Book) on
the hospital intranet.
The Electronic Clinical Information Editorial Group is responsible for dissemination and awareness
of the guideline. These guidelines are promoted at junior and senior doctor inductions.
Document configuration information
Author(s):
Other contributors:
Approved by:
Issue no:
File name:
Supercedes:
Chief Pharmacist and consultant microbiologists
Dr. N Levy, Dr. A Burns and Dr C Laroche, Dr. R Bannon
Drugs and Therapeutics Committee
5
Antibiotic Guidelines
CG10118-4
Additional Information:
Source: Consultant Microbiologists
Status: Approved
Issue date: May 2009
Valid until: February 2012
Page 24 of 24