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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. Page 4 of 24 West Suffolk Hospital NHS Trust 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 Page 5 of 24 West Suffolk Hospital NHS Trust 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. Page 6 of 24 West Suffolk Hospital NHS Trust 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 Page 7 of 24 West Suffolk Hospital NHS Trust 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 West Suffolk Hospital NHS Trust 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 West Suffolk Hospital NHS Trust 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 West Suffolk Hospital NHS Trust 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 West Suffolk Hospital NHS Trust 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 West Suffolk Hospital NHS Trust 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 West Suffolk Hospital NHS Trust 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 Page 18 of 24 West Suffolk Hospital NHS Trust CG10118-5 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 West Suffolk Hospital NHS Trust CG10118-5 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 West Suffolk Hospital NHS Trust 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 West Suffolk Hospital NHS Trust CG10118-5 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 West Suffolk Hospital NHS Trust 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 West Suffolk Hospital NHS Trust CG10118-5 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