Download worcestershire secondary care adult antibiotic prescribing policy

Trust Policy
WORCESTERSHIRE SECONDARY CARE
ADULT ANTIBIOTIC PRESCRIBING POLICY
Department / Service:
Originator:
Accountable Director:
Approved by:
Pharmacy/Microbiology/Infectious Diseases
C R Catchpole
Date of approval:
Revision Due:
Target Organisation(s)
Target Departments
Target staff categories
7th January 2015
7th January 2017
Worcestershire Acute Hospitals NHS Trust
All departments
All clinical staff prescribing and administering antibiotics
Mark Wake
Accountable Director
Signature:
Chair Steve Graystone
Purpose of this document:
This policy covers all adult patients being prescribed antibiotics within WAHT. It provides
guidance on empirical antimicrobial therapy for commonly encountered and other important
infections, and surgical prophylaxis. All clinical staff who prescribe, administer and monitor
antimicrobial therapy should familiarise themselves with this policy, and be able to defend
deviation from its guidance.
Key amendments to this Document:
Date
Sep 2010
Sep 2010
Sep 2010
Sep 2010
Sep 2010
May 2011
May 2012
July 2012
Amendment
Additions to information and assessment of penicillin/betalactam allergy
Addition of link to NICE guidance on bacterial meningitis
and meningococcal septicaemia (Clinical guideline 102)
Change of dosing regimen for gentamicin to 5mg/kg
Amendments to febrile neutropenic policy
Change of format to meet requirements of Trust Policy
template
Addition of statement on epididymoorchitis, (approved
April/May 11)
Clarification of recommendations for human and animal
bites for penicillin allergic patients (6.16)
Update to general Principles (6.1)
Update to Penicillin/beta-lactam allergy (6.4)
Update to guidelines for treatment of cellulitis and
necrotising fasciitis (6.10)
Addition of link to HPA guidance for management of PVL
toxin producing staphylococcal infection (6.10, 6.11)
Update to guidelines for treatment of community and
hospital acquired pneumonia (6.11)
Update to guidelines for treatment of infective endocarditis
(6.13)
By:
C Catchpole
C Catchpole
C Catchpole
C Catchpole
C Catchpole
A Dyas
C Catchpole
C Catchpole
Worcestershire Secondary Care Adult Antibiotic Prescribing Policy
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July 2013
January
2014
February
2014
April
2014
7th May
2014
Septemb
er 2014
October
2014
January
2015
Update to guidelines for treatment of meningitis (6.14)
Update to Factsheet on splenectomy and infection (6.17)
Update on Monitoring and Compliance (13.)
Update to Radiological procedures (TRUS guidance)
Update to Antibiotics in Accident & Emergency (6.16)
Minor amendments approved by C Catchpole
Removal of norfloxacin for Spontaneous Bacterial
Peritonitis
Minor amendments approved by C Catchpole (clindamycin
dose p 27)
Update to Pyelonephritis wording (6.9)
Additional statement on Staph aureus BSI – Minor
amendment approved at TIPCC 28/04/2014
Update to general principles
Approved at MSC
Changes to antibiotic prophylaxis for obstetrics
T Evans
J Stockley
T Evans
T Evans
TIPCC
T Evans
T Evans
Approved at Medicines Safety Committee
Dose amendment to pneumonia section
Update to surgical prophylaxis section (to include breast
surgery and major head and neck surgery)
T Evans
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Contents page:
1.
Introduction
2.
Scope of the Policy
3.
Definitions
3.1
Antibiotics
3.2
Empirical therapy
3.3
Prophylaxis
4.
Responsibility and Duties
4.1
Executive Directors
4.2
Divisions, Directorates, General Managers and Clinical Directors
4.3
Medical Staff
4.4
Matrons and Specialist Nurses and other nursing staff
4.5
Pharmacy Department
4.6
Consultant Microbiologists/Infectious Disease Physicians
5.
Equality requirements
6.
Policy detail
6.1
General Principles
6.2
MRSA
6.3
Clostridium Difficile
6.4
Penicillin/Beta-Lactam Allergy
6.5
Surgical Prophylaxis
General
Gastrointestinal surgery
Gynaecological surgery
Obstetrics
Orthopaedic surgery
Urological surgery
Vascular surgery
Radiological procedures
6.6
6.7
6.8
Febrile Neutropenics
Septicaemia in Immunocompetent Patients
Gastrointestinal Infections
Eradication of Helicobacter pylori
Spontaneous Bacterial Peritonitis (hepatic failure)
6.9
Urinary Tract Infections And Related Conditions
Uncomplicated UT
Pyelonephritis
Epididymoorchitis
6.10
Skin and Soft Tissue Infection
Cellulitis
Gas Gangrene
Necrotising Fasciitis
6.11
Lower Respiratory Tract Infections
Acute exacerbation of COPD
Community Acquired Pneumonia
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Aspiration Pneumonia
6.12
6.13
Clostridium Difficile
Endocarditis
Prophylaxis of Endocarditis
Treatment of Endocarditis
6.14
6.15
6.16
Treatment of Suspected Meningitis
Septic Arthritis and Osteomyelitis
Antibiotic Use in Accident and Emergency
Skin and Soft Tissue Infection
Compound Fractures
Dental Abscesses
Tonsillitis
Otitis Media
Lower Respiratory Tract Infection
Pelvic Inflammatory Disease – refer to intranet Trust guideline WAHT-GYN008
Suspected Meningitis – see Treatment of Suspected Meningitis (6.14 above)
Urinary Tract Infection
6.17
Factsheet on Splenectomy and Infection
The Spleen
What if the spleen has been removed or ceases to function?
How great is the risk of infection after splenectomy
How long does the risk of infection last after splenectomy?
What can be done to reduce the risk?
Vaccination against infection
Antibiotics
6.18
Meticillin-Resistant Staphylococcus Aureus – (Mrsa)
Treatment of Patients and Staff
7.
Financial risk assessment
8.
Consultation
9.
Approval process
10.
Implementation arrangements
11.
Dissemination process
12.
Training and awareness
13.
Monitoring and compliance
14.
Development of the Policy
15.
Appendices
Appendix 1
Equality impact assessment tool
Appendix 2
Plan for dissemination of Key document
Appendix 3
Financial Risk Assessment
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1.
Introduction
The purpose of this policy is to provide guidelines for initial empirical (blind) therapy for
clinical infection based on likely causative organisms and local antimicrobial sensitivity
data. Doses given are generally those for adults with normal renal and hepatic
function. Further details of side effects interactions and contraindications, etc. can be
found in the British National Formulary or from Medicines Information ext. 30235. It
also contains guidance on appropriate regimens for surgical antibiotic prophylaxis.
This policy does not cover every eventuality. Advice on antibiotic therapy can also be
obtained from the Consultant Microbiologists and Infectious Disease Physicians.
2.
Scope of the Policy
This policy is intended for use by all clinical staff that prescribe, administer or monitor
antibiotic agents to patients in the acute Trust. It also complements the
Worcestershire primary care prescribing guidelines.
3.
Definitions
4.
3.1
Antibiotics
Agents which have therapeutic activity against microorganisms (e.g. bacteria,
fungi, viruses, protozoans), and which are used in the prevention and
treatment of infection.
3.2
Empirical therapy
Antibiotic agents which are administered to treat infection before the
identification of the causative organism is known. Choice should be based on
knowledge of likely pathogens in the clinical situation.
3.3
Prophylaxis
Antibiotic agents used to prevent infection, usually to cover a defined period of
increased risk, e.g. surgery.
Responsibility and Duties
Overall responsibility for this Policy rests with the Trust Board. Operational
responsibilities are delegated as follows:
4.1
Executive Directors
The lead Executive Director for this Policy will be the Medical Director. In
addition, all Executive Directors will be responsible for ensuring that:


All appropriate staff are informed of the terms of the policy
The policy is implemented and operated effectively within the sphere of
their control
4.2
Divisions, Directorates, General Managers and Clinical Directors
Divisional and Directorate management teams have responsibility for ensuring
full compliance with this policy through Clinical Governance structures and
arrangements. They are also responsible for ensuring that data is provided as
required for performance monitoring purposes by the Trust.
4.3
Medical Staff
Medical staff are expected to implement this policy, and in the case of
Consultants, ensure that it is followed by all staff who care for their patients.
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Consultant staff have an additional responsibility in ensuring that their junior
staff have received adequate training in the use of antibiotics and antibiotic
stewardship.
4.4
Matrons and Specialist Nurses and other nursing staff
Nurses will work with the Pharmacy Department and Medical staff to maintain
the highest standards of practice with regards to the prescription,
administration and monitoring of antibiotic therapy.
4.5
Pharmacy Department
The Pharmacy Department will contribute to safe antibiotic prescribing and
stewardship through regular review of prescription charts and close liaison with
medical and nursing staff, under the leadership of the Antimicrobial
Pharmacist.
4.6
Consultant Microbiologists/Infectious Disease Physicians
The Consultant Microbiologists and Infectious Disease Physicians will provide
expert knowledge and training to support and augment the good antimicrobial
prescribing practice contained in the policy, and promote high standards in
antimicrobial stewardship within the Trust.
5.
Equality Requirements
An Equality Impact Assessment has been undertaken in accordance with Trust policy
and attached at Appendix 1.
6.
Policy Detail
6.1
General principles
 Antibiotics should only be prescribed for proven or clinically suspected bacterial
infection unless recommended for prophylaxis.

Choice of antibiotic should be guided by clinical signs and symptoms, history and
recent laboratory results.

Many antibiotics require dosage adjustment in renal impairment. For further
advice contact your ward pharmacist or medicines information (WRH Ext: 30235).

In certain cases, obese patients may require higher doses of antimicrobial and
other agents. This may include surgical prophylaxis prescribing as well as
treatment of established infection. Please discuss such cases with a
microbiologist or infectious disease physician.

When treating blind (empirical therapy), and as a general rule, use the narrowest
spectrum drug that will cover the most likely pathogens. Where microbiological
data, e.g. MRSA status, culture results and sensitivities are available, or become
available after treatment is started, these should be taken into account. Always
check (using electronic results system) if results of previous microbiology
(inpatient or outpatient/GP) should influence empirical therapy, e.g. previous
infection with MRSA, ESBL producing organism, or C difficile.
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
If clinically safe it is recommended to take samples for cultures before initiating
antimicrobial treatment (there are however, notable exceptions, such as
suspected bacterial meningitis or meningococcal septicaemia).

Only use the IV route when patient is:
 nil by mouth
 a rapid therapeutic concentration is required
 very high drug levels are desirable, or
 gut absorption is unreliable
or if no oral equivalent of the optimal agent is available

All IV antibiotics should be switched to oral as soon as is clinically indicated:
General Inclusion Criteria for IV to oral switch:
o Able to swallow and tolerate oral fluids
o Clinical improvement
o Temperature 36ºC - 38ºC for at least 48hrs
o Heart rate <90bpm for previous 12hrs
o White cell count (WCC) between 4 and 12x109L
o Oral formulation or alternative available
Specific Exclusion Criteria for routine IV to oral switch:
o Oral route compromised:
o Vomiting/nil by mouth
o Unconscious without enteral feed tubes
o Mechanical swallowing disorder
o Oral fluids not tolerated
o Absorption problem- diarrhoea/steatorrhoea
o Continuing severe sepsis - 2 or more from
o Temp >38ºC or <36ºC
o Heart beat >90bpm
o Respiratory rate >20/min
o Worsening WCC and/or CRP
o Febrile with neutropenia - neutrophils <1
�Specific indications
- Meningitis/encephalitis
- Endocarditis
- Immunosuppression
- Osteomyelitis
- Septic arthritis
- Deep abscess
- Cystic fibrosis
- severe soft tissue infections such as group A
- severe streptococcal infections
- Hickman (central) line infection
- No oral formulation of the drug or specified alternative available
(Source:
http://www.dgprescribingmatters.co.uk/documents/Intravenous%20to%20oral%20guidelines
%5b1%5d.pdf)
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
Consider the relevance of microbiology culture results in order to distinguish
infection from colonisation. If in doubt discuss with a microbiologist.

The first dose of all therapeutic antibiotics should be prescribed as a ‘stat’ to
ensure prompt commencement of treatment; subsequent doses should be
prescribed for administration at regular intervals (but ensure that time interval
between first ‘stat’ dose and regular prescription is appropriate, particularly
important for gentamicin/tobramycin and vancomycin).

All antibiotic treatment should be reviewed on a daily basis and the course
continued for the minimum duration recommended for the specific indication or as
long as is clinically necessary. There should be a documented plan in the clinical
record for duration of antibiotic therapy and when review is required.

Non-drug options, such as surgical debridement of wounds and drainage of
abscesses should be considered.

The need for intravenous antibiotics is not necessarily a reason for admission as
an inpatient. Likewise, prolonged treatment with intravenous antibiotics should
not necessarily prevent discharge. Familiarise yourself with arrangements for
outpatient or home intravenous antibiotic provision. Contact via: tel. 01905
681818, fax 01905 681402, or radiopage via switchboard 0765952913.

Always take a history of any true allergy to antibiotics. Ascertain what patients
mean by ‘allergy’; some may be mislabelled as allergic and consequently receive
potentially less appropriate antibiotics (see below).

Drug level monitoring is necessary for courses of gentamicin or vancomycin
WAHT-PHA-004 and WAHT-PHA-003. NB: It is essential that all individuals
prescribing or dispensing these agents familiarise themselves with these policies.

Documentation of the reason and the choice of antibiotic in the notes is
mandatory for all prescriptions. The indication for antibiotic prescription
must also be recorded on the prescription sheet. Specify the intended length
of course in the notes and on the treatment sheet. Many infections are
adequately treated by a 5 day course of antibiotics, and all prescriptions should
be marked for review at 5 days.

Immunosuppression, e.g. from HIV infection should be considered in any patient
presenting with infection, particularly if recurrent or unexplained, associated with
lymphopenia, or if risk factors are identified.

The ID team should be notified of all patients with sepsis admitted through MAU
at WRH, and the Sepsis Pathway should be followed (Sepsis Protocol 1 2).
6.2
MRSA
For all indications, where there is suspected MRSA infection, refer to section
6.18 of these guidelines.
All patients should be assessed for risk of MRSA colonisation/infection
before prescribing empirical antimicrobials, as increased risk should
influence choice of agents used (see section 6.18).
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Remember to review all previous microbiology reports, including those
from general practice (available electronically) to establish whether
patient has been MRSA positive.
If required please discuss with a Consultant Microbiologist or ID physician
before starting empirical therapy.
6.3
Clostridium difficile
For all indications, do not prescribe cephalosporins, quinolones, or
clindamycin unless no other alternatives are appropriate, particularly in the
elderly owing to the risk of Clostridium difficile infection (CDI). These agents
will only be dispensed following discussion and agreement with a
Consultant Microbiologist (with the exception of cefotaxime/ceftriaxone
for suspected meningitis, and in paediatrics/obstetric departments).
If necessary contact a Consultant Microbiologist or ID physician for advice.
6.4
Penicillin/ beta-lactam allergy
Penicillins/beta-lactams include a wide range of agents, e.g. amoxicillin
(including co-amoxiclav), flucloxacillin, cephalosporins (cefuroxime,
ceftriaxone, cefalexin, and others), tazocin, and the carbapenems (including
meropenem and ertapenem). ‘Allergy to penicillin’ is commonly reported and
recorded in medical notes, and is often simply accepted without obtaining a
detailed history of the reaction. Many patients (up to approx. 20%) who report
a reaction, (e.g. gastrointestinal symptoms or feeling faint) are not truly allergic
and as a result penicillins are unnecessarily withheld, which may affect clinical
outcome.
General hypersensitivity reactions (e.g. rashes) to penicillin occur in between 1
and 10% of exposed patients but true anaphylactic reactions (which can be
fatal) occur in less than 0.05% of treated patients.




Obtain an accurate allergy status from the patient (see below) and always
document this in the medical notes and fill in the allergy box on the drug chart
with details of any previous reactions
Be aware of which antimicrobials are penicillins/beta-lactam agents. Patients
with allergy to penicillin should be regarded as allergic to all penicillin–like
agents (see above and ‘traffic light poster’ in clinical areas) and potentially
allergic to other beta-lactams, e.g. cephalosporins and
meropenem/ertapenem, although these may often be safely administered.
Patients with a history of anaphylaxis, or urticaria immediately after
administration of a penicillin (IgE mediated) are at risk of immediate
hypersensitivity to all beta-lactam agents; these individuals should never
normally receive a penicillin, a cephalosporin, meropenem/ertapenem, or any
other beta-lactam antibiotic. If required consult with a senior colleague or a
Microbiologist. Signs and symptoms of immediate hypersensitivity include,
dyspnoea, swelling, and urticaria with or without a rash.
Individuals with a history of a minor rash (i.e. non-confluent restricted to a
small area of the body), or a rash that occurs more than 72 hours after
administration of penicillin or a related agent may tolerate treatment with betalactams, e.g. meropenem/ertapenem if indicated by the severity of illness or
optimal antibiotic choice, but this should be administered under observation in
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hospital, and fully documented in the patient’s medical notes – discuss with a
Microbiologist/ID physician.
Drug intolerance (see above) is not an indication of allergy, or a reason to
necessarily avoid beta-lactam antibiotics where their use is indicated

Taking a clinical history of penicillin allergy: What to Ask









What was the patient’s age at the time of the reaction?
Does the patient recall the reaction? If not, who informed them of it?
How long after beginning penicillin did the reaction begin?
What were the characteristics of the reaction?
Anaphylaxis: i.e. tongue, lip, throat or facial swelling, wheeze or
collapse
Stevens Johnson syndrome/toxic epidermal necrolysis
Urticaria
Other rash
Itch
Other symptoms
What was the route of administration?
Why was the patient taking penicillin?
What other medications was the patient taking? Why and when were
they prescribed?
What happened when the penicillin was discontinued?
Has the patient taken antibiotics similar to penicillin (for example,
amoxicillin, flucloxacillin, cephalosporins) before or after the reaction?
The GP’s surgery may be able to confirm this. If yes, what was the
result?
Establishing the nature of the reported allergy
1)
Immediate hypersensitivity
Immediate reactions to penicillin/beta-lactam administration are often associated
with symptoms of anaphylaxis such as diffuse erythema, pruritus, urticaria,
angio-oedema, bronchospasm, laryngeal oedema, hypotension or cardiac
arrhythmias, either alone or in combination. Anaphylactic reactions are most
commonly seen in adults aged between 20 and 49 and usually start within one
hour of taking the antibiotic, usually at the first dose. These reactions are IgE
mediated.
Patients reporting such immediate reactions must NOT be given any betalactam antibiotic again.
2)
Moderate allergy
Other IgE medicated reactions to penicillin can occur from 1 to 72 hours after
administration and may be manifested by urticaria, angio-oedema, laryngeal
oedema and wheezing.
Beta-lactam antibiotics should usually not be given to patients who report such
symptoms without immunological investigations. If alternative treatment for a
life-threatening infection is likely to be less effective, the case should be
discussed with the consultant looking after the patient and/or ID/Microbiology.
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3)
Other reactions
Reactions to penicillin occurring after 72 hours of drug administration and
rashes not involving the whole body are unlikely to be IgE mediated. Drugindependent rashes are common in patients with viral infections – which may
have been unnecessarily treated with an antibiotic; infections with bacteria can
also be associated with a rash. Many patients taking penicillin may also be
taking other medications that can cause rashes. Hence, patients with infections
who develop a rash while taking a penicillin antibiotic should not be
automatically labelled as penicillin-allergic. If a detailed history of a patient’s
reaction to penicillin indicates that the rash was strictly maculopapular, with no
signs of a type I reaction, and if a non-beta-lactam antibiotic is not appropriate,
then it is probably safe to give a beta-lactam antibiotic (the risk is low).
Choice of antibiotic in patients with penicillin allergy
If the infection can be adequately treated with a non-beta-lactam antibiotic such as a
macrolide, the safest and easiest option is to use the alternative. However, the future
needs of the patient should also be considered and if it is likely that further courses of
antibiotics will be needed to treat severe infections, (e.g. associated with neutropenia),
the opportunity should be taken to establish the nature of the allergy and possible
future treatment options. Patients with a history of anaphylaxis, urticaria or respiratory
symptoms associated with penicillin allergy must NOT be given a beta-lactam
antibiotic.
Selecting a non-beta-lactam antibiotic
Suitable alternative antibiotic regimens are provided in these antibiotic guidelines. If in
doubt, discuss with a Microbiologist/ID physician.
It should be remembered that the safety record of all alternative antibiotics is probably
not as good as that for beta-lactams. This is why it is important to get a much
information as possible related to reports of allergy. This may require contacting the
GP to clarify the nature of reported allergies if a clear history is not available from the
patient. If in doubt, consult the BNF or Manufacturer’s Summary of Product
Characteristics for contra-indications and precautions.
Suggested scheme for deciding on antibiotic:
PREVIOUS TYPE OF ALLERGY/REACTION:
ILLNESS SEVERITY/
SERIOUSNESS:
NO RASH or
WHEEZE or FACIAL
OEDEMA
DELAYED (>1h)
WIDESPREAD
MACULAR RASH
URTICARIA
ANAPHYLAXIS
WHEEZE
FACIAL
OEDEMA
Mild illness
Either beta-lactam
or alternative
Alternative
Alternative
Alternative
Moderate illness*
Beta-lactam
Either beta-lactam
or alternative
Alternative
Alternative
Life-threatening
illness*
Beta-lactam
Beta-lactam
Discuss with
Microbiology/ ID
Alternative
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*assess whether there is a moderate or life threatening illness where a beta-lactam is
considered to be the optimal treatment
6.5
Surgical Prophylaxis
General

Administer antibiotic before incision. All 1st doses administered by anaesthetist at
induction (except vancomycin, ciprofloxacin and oral antibiotics which should be
administered on the ward). It is essential that there are therapeutic levels of
antibiotic at the desired site, prior to the incision being made. Failure to achieve
this results in increased infection rates.
Consider oral antibiotics for minor operations, as per regimen for ERCP. These can
be given on the ward, one hour before incision.
Maintain adequate concentration until closure, i.e. single doses for procedures less
than 4 hours, repeated doses for longer procedures. All antibiotics included in this
section of the policy to be kept in theatres (including second line agents for patients
with allergies).
All elective surgical patients should now be screened for MRSA carriage prior to
admission. Make sure the results are checked; if MRSA positive, antibiotic
prophylaxis may need to be adjusted to provide adequate cover against this
organism (see below).
NB co-amoxiclav and clindamycin provide adequate cover against anaerobic
organisms in most situations and the addition of metronidazole is unnecessary.




Breast Surgery
Indication
Malignant,
implant,
diabetic
patients, total
duct
excision,
second
surgery, wire
localisation,
axillary node
clearance,
reduction
and
augmentatio
n
All
reconstructio
ns
Drug(s)
Co-Amoxiclav
Dose
1.2g
Route
IV
Frequency
At induction
Notes
Flucloxacillin
AND
Gentamicin
1g
IV
At induction
120mg
IV
If confirmed penicillin
allergy or MRSA
positive use
Vancomycin 1g single
dose and gentamicin
120mg IV. If
reconstruction with
acellular dermal
matrix, continue oral
flucloxacillin post-op
until drains removed.
If confirmed penicillin
allergy or MRSA
positive use
Vancomycin 1g single
dose and gentamicin
120mg IV
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Gastrointestinal surgery
Indication
All GI
surgery
including
biliary tract
Emergency
lower GI
surgery/ high
risk of sepsis
Drug(s)
Co-Amoxiclav
Dose
1.2g
Route
IV
Amoxicillin
AND
Gentamicin
AND
Metronidazole
Gentamicin
AND
Metronidazole
1g
IV
120mg
IV
500mg
120mg
IV
IV
500mg
IV
ERCP
Gentamicin
120mg
IV
hepatobiliary
sepsis
(prophylaxis/
treatment)
Amoxicillin
AND
Gentamicin
500mg
IV
1 hour before
procedure
TDS
5mg/kg
(max
560mg
dose)
500mg
500mg
IV
OD regimen
IV
IV
TDS
TDS
5mg/kg
(max
560mg
dose)
500mg
IV
OD regimen
Patients with
confirmed
penicillin
allergy
Lower
abdominal
sepsis/
perforation
(prophylaxis/
treatment)
AND
Metronidazole
Amoxicillin
Frequency
At induction
(but see note
on vancomycin
administration)
At induction
(but see note
on vancomycin
administration)
.
1 hour preoperatively
AND
Gentamicin
AND
Metronidazole
Notes
If known MRSA add
Vancomycin 1g single
dose.
If known MRSA
substitute
Vancomycin 1g IV for
Amoxicillin.
If high risk sepsis use:
Clindamycin 600mg
IV & Gentamicin
5mg/kg (max 560mg
dose).
If confirmed penicillin
allergy omit
amoxicillin
If confirmed penicillin
allergy use:
Clindamycin 600mg
IV QDS & Gentamicin
5mg/kg/OD regimen
(max 560mg dose).
NB: increased C.
difficile risk
IV
TDS
If penicillin allergy use gentamicin and metronidazole alone.
If gentamicin contra-indicated consider use of meropenem (NB: amoxicillin and metronidazole
alone does NOT provide sufficient cover).
Pancreatitis
with
suspected or
confirmed
pancreatic
necrosis
Tazocin
4.5g
IV
TDS
If confirmed penicillin
allergy use:
Ciprofloxacin 400mg
BD IV &
Metronidazole 500mg
TDS IV
NB: increased C.
difficile risk:
2nd Line
agents for
Tazocin
4.5g
IV
TDS
Discuss with
microbiologist
If confirmed penicillin
allergy: discuss with a
consultant
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microbiologist
abdominal
sepsis
Gynaecological surgery
Indication
All
Gynaecologi
cal surgery
Penicillin
allergy
Drug(s)
Co-amoxiclav
Dose
1.2g
Route
IV
Frequency
At induction
Notes
Cefuroxime
AND
Metronidazole
1.5g
IV
At induction
500mg
IV
If >65 years or
other risk factor
for C difficile
infection please
discuss with
Consultant
Microbiologist
Drug(s)
Co-amoxiclav
Dose
1.2g
Route
IV
Frequency
At
induction. If
prosthetic
material or
free flap
give 2
further postop doses at
8 and
16hours.
Notes
Drug(s)
Metronidazole
And
Dose
1g
Route
Rectal
supposi
tory
Frequency
1 hr before
skin incision
Notes
Cefuroxime
1.5 g
Head and Neck surgery
Indication
Major head
and neck
surgery (with
mucosal
breach)
If confirmed
penicillin allergy
or MRSA
positive use
vancomycin 1g
IV and
metronidazole
500mg IV
Obstetrics
Indication
Elective
caesarean
section
IV
Emergency
caesarean
section
Metronidazole
And
1g
Cefuroxime
1.5 g
Rectal
supposi
tory
IV
Where a
Clindamycin
woman has a AND
history of an Gentamicin
immediate
600mg
IV
120mg
IV
30 mins
before skin
incision
Administer
wherever
possible
within the
30 minutes
before skin
incision, or
as soon as
practical.
At induction
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The rectal dose
of
metronidazole
should be given
by the
obstetrician/mid
wife at the time
of decision for
emergency
caesarean
section.
Clindamycin over
20 minutes
Gentamicin slow
bolus over 5
minutes
Trust Policy
hypersensitiv
ity reaction to
penicillin or
an allergy to
cephalospori
ns
NB: Group B Streptococcus carriage is not routinely screened for, however if +ve HVS or urine
culture, as per local departmental guidelines.
Orthopaedic surgery
Indication
Elective
surgery
without
prosthetics
and all
surgery with
prosthetics,
fixators or
other
hardware
If confirmed
penicillin
allergy
or known or
suspected to
be colonised
with MRSA
Drug(s)
Gentamicin
AND
Flucloxacillin
Dose
120mg
Route
IV
Frequency
Stat
Notes
1g
IV
Stat (2 further
doses if long
operation or
considerable
blood loss)
1st choice
Vancomycin
AND
Gentamicin
1g
IV
120mg
IV
800mg
IV
120mg
IV
Prior to
induction over
100 minutes
Stat
or
2nd choice
Teicoplanin
AND
Gentamicin
If MRSA positive see
below.Extend Flucloxacillin
prophylaxis to 3 further
doses (6hrly) for
hemiarthroplasty and
prosthetic implant surgery.
Vancomycin must be given
on the ward before going
to theatre so that adequate
tissue concentration is
achieved prior to incision.
Avoid if significantly
impaired renal function,
contact microbiologist for
advice
Stat
stat
Open fractures – see accident and emergency section 6.16
Urological surgery
Indication
All urological
procedures
Drug(s)
Gentamicin if recent urine
sensitivities indicate
Dose
120mg
Route
IV
Frequency
At Induction
Notes
Review recent
urine culture
results, and
ensure cover is
adequate; if
MRSA contact
microbiology.
If gentamicin
contra-indicated
use Coamoxiclav 1.2g
IV
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Trust Policy
Vascular surgery
Indication
Major
vascular
surgery
Severe
penicillin
allergy, i.e.
anaphylaxis
Drug(s)
Vancomycin
Dose
1g
Route
IV
Frequency
Over 100
minutes
repeated 12
hours later
Co-amoxiclav
1.2g
IV
Gentamicin
120mg
IV
Give before
induction, then
8 and 16 hours
later
1 hour preoperatively
then 12 hours
later
500mg
IV
AND
AND
Metronidazole
Notes
Vancomycin must
be given on the
ward before going
to theatre so that
adequate tissue
concentration is
achieved prior to
incision
20 mins before
induction, then
8 and 16 hours
later
Radiological procedures
Indication
Transrectal
biopsy of
prostate
Drug(s)
Ciprofloxacin
AND
Metronidazole
AND
Gentamicin
Dose
500mg
Route
PO
400mg
or
1g
PO
160mg
IV
Frequency
1 hour
before
procedure
Notes
Continue with
ciprofloxacin
PO 500mg bd
for 2 days
PR
1 hour
before
procedure
If patient is receiving antibiotic therapy at time of biopsy, establish indication and review with any
microbiology results. Active urinary tract infection may be an indication to delay the procedure –
discuss with microbiology if required.
6.6
Febrile Neutropenia
Indication
1st line
febrile
neutropenic
Drug(s)
Meropenem
Dose
1g
Route
IV
Frequency
TDS
Notes
1g
IV over
100
minutes
BD
Vancomycin
levels should
be monitored
AND If line infection suspected
add
Vancomycin
See intranet
guidelines
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Trust Policy
Severe
Discuss with microbiologist
penicillin
allergy i.e.
anaphylaxis
Non-neutropenic sepsis (no lines, not pre-treated) – treat as septicaemia in immunocompetent
patients below (6.7).
6.7
Septicaemia in Immunocompetent Patients
Treatment should be guided by patient’s history; there will usually be a focus for the infection (for
example, chest, lower GI tract). This should guide initial treatment. However, an empirical starting
point is provided below:
Indication
Empirical
treatment of
septicaemia
Drug(s)
Flucloxacillin
AND
Gentamicin
+/Metronidazole
Dose
1g
Route
IV
Frequency
QDS
IV
5mg/kg
(max
560mg
dose)
500mg
IV
One dose
initially and
check level
6-14 hrs.
post dose
Notes
See intranet for
guidance on
Gentamicin
dosing
Review need to
continue
gentamicin at
24hrs
TDS
Depends on clinical picture, nature of allergy, etc. Discuss with microbiologist/ID
Physician if required
See intranet for
Vancomycin
1g
IV
BD
guidance on
AND
Gentamicin and
Metronidazole
500mg
IV
TDS
Vancomycin
AND
dosing
Gentamicin
5mg/kg
IV
One dose
(max
only
560mg
dose)
Further treatment should be guided by blood culture and other microbiology results
Refer to the Sepsis Pathway (Sepsis Protocol 1 2) and inform ID team of all patients referred
through MAU at WRH.
S. aureus bacteraemia has a high mortality: it requires 14 days IV antibiotics, and an
echocardiogram
Penicillin
allergy
Known or
suspected
colonisation
/infection with
MRSA
6.8
Gastrointestinal Infections
Eradication of Helicobacter pylori
See HPA guidance HPA guidance and select an appropriate regime utilising medicines in the
current Trust Formulary.
Spontaneous Bacterial Peritonitis (hepatic failure)
Indication
Prophylaxis
Drug(s)
Co-trimoxazole
Dose
480mg
Route
Oral
Frequency
daily
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Notes
NB: increased
C. difficile risk
Contact
microbiology if
Trust Policy
Treatment
6.9
Co-amoxiclav
1.2g
IV
Eight hourly
history of C.
difficile
diarrhoea
If confirmed
penicillin
allergy, contact
microbiologist
for advice
Urinary tract infections and related conditions
Treatment should be guided by previous antibiotic use and by culture results.
Uncomplicated UTI
(amend if required once culture results available)
Indication
Drug(s)
Dose
st
1 line
Trimethoprim
200mg
Route
PO
Frequency
BD
2nd line
Co-amoxiclav
375mg
PO
TDS
Severe:
Co-amoxiclav
1.2g
IV
TDS for 5
days
(switch to
PO when
appropriate)
AND
Gentamicin
5mg/kg
(max 560mg IV
dose)
OD
regimen,
review at 24
hrs and
switch to
appropriate
agent
based on
culture
results
Penicillin
allergy
Notes
Treat lower UTIs
not associated
with
catheterisation
or surgery for 3
days only.
Cefalexin may
also be used in
pregnancy
(treat for 7 days)
Avoid antibiotics
unless clinically
unwell in which
case change
catheter and give
one of regimens
described. See
additional notes
on Gentamicin
dosing
Gentamicin alone, as
above.
If infection with Extended Spectrum Beta-lactamase (ESBL) producing organisms is suspected
– see WAHT-INF-018 via Document Finder on the intranet. Check for previous microbiology
results, including from General Practice, discuss with Consultant Microbiologist.
Pyelonephritis
Indication
1st line
Drug(s)
Co-amoxiclav
Dose
1.2g
Route
IV
Frequency
TDS
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Notes
Review at 48
hours to
Trust Policy
+/Gentamicin
If penicillin
allergy
Then:
Co-amoxiclav
Gentamicin
5mg/kg
IV
(max 560mg
dose)
OD regimen
625mg
5 mg/kg
(max 560
mg dose)
PO
IV
TDS
OD regimen
Dose
1.2g
Route
IV if
neede
d
Frequency
TDS
consider oral
therapy
If gentamicin
contra-indicated
and non-severe
penicillin allergy
(see 6.4) use
meropenem
500 mg IV TDS.
If severe
penicillin allergy
discuss with
microbiologist
Epididymoorchitis
Indication
Elderly
men, cause
thought to
be urinary
tract
organism,
1st line
As above,
second line
Drug(s)
Co-amoxiclav
Ciprofloxacin
500mg
Oral
BD
Younger
men, cause
may
include
sexually
transmitted
pathogens
Ciprofloxacin
500mg
Oral
Single dose
100mg
Oral
BD for 10-14
days
or
625mg
TDS
Notes
10-14 days
treatment,
convert to oral
as soon as
possible
Oral
AND
Doxycycline
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10 days
treatment,
avoid use in inpatients if
possible
NB: increased
C. difficile risk
Based on 2001
National
guideline for the
management of
epididymoorchitis
Clinical
Effectiveness
Group
(Association for
Genitourinary
Medicine and
the Medical
Society for the
Study of
Venereal
Diseases)
Trust Policy
6.10
Skin and Soft Tissue Infection
Cellulitis
Indication
Cellulitis
Drug(s)
Flucloxacillin
Dose
1g-2g
Route
PO/IV
Frequency
QDS
If diabetic add metronidazole see
below
If history of or suspected MRSA
infection give: Vancomycin instead
of Flucloxacillin
Penicillin
allergy or
failure to
respond to
the above
regime
Clindamycin
If patient
diabetic
ADD
Metronidazole
600m
g
Then after 5 days switch to
Clindamycin (see above if MRSA
suspected)
IV
QDS
PO
QDS
PO
TDS
450m
g
400m
g
Notes
Dose depends
on severity of
cellulitis and
weight of
patient.
Review daily
and switch to
oral treatment
according to
clinical
progress.
Usually at least
5 days
treatment with
intravenous
antibiotics will
be required.
Monitor renal
function.
Contact
microbiology/I
D for advice if
needed
To complete
in total at
least 10 days
treatment
NB:
increased C.
difficile risk:
Discuss with
microbiologist
To complete
in total at
least 10 days
treatment
In addition to
above
antibiotics
(not required
if clindamycin
used)
Consider cover for Pseudomonas if associated with diabetic foot lesions.
If cellulitis is recurrent, consider treating for fungal skin infections.
If PVL toxin producing Staph aureus is identified as the cause of infection, follow the HPA
guidance regarding management
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Trust Policy
Gas Gangrene
Indication
Penicillin
allergy
Drug(s)
Benzylpenicillin
AND
Clindamycin
AND
Gentamicin
Dose
2.4g
Route
IV
Frequency
QDS
600mg
IV
QDS
5mg/kg
(max
560mg
dose)
IV
OD regimen
Clindamycin
AND
Gentamicin
600mg
IV
QDS
5mg/kg
(max
560mg
dose)
IV
OD regimen
Notes
NB:
increased C.
difficile risk:
Discuss with
microbiologist
if required.
Adjust
gentamicin
dosage by
monitoring
levels
NB:
increased C.
difficile risk:
Adjust
gentamicin
dosage by
monitoring
levels
Necrotising Fasciitis
NB: Surgical debridement (often extensive and requiring repeat procedures) is an important part
of the management of this condition.
Based on clinical diagnosis or if group A Streptococcus isolated (NB: infection control precautions
required). Contact microbiology/ID for advice.
Indication
Drug(s)
Dose
Route Frequency
Notes
NB: increased
Flucloxacillin AND
2g
IV
QDS
C. difficile risk:
Clindamycin
Discuss with
AND
600mg IV
QDS
microbiologist
Meropenem
1g
IV
TDS
Adjust
Penicillin
Clindamycin
600mg IV
QDS
gentamicin
allergy
AND
dosage by
Gentamicin
5mg/kg IV
OD regimen
monitoring
(max
levels
560mg
dose)
6.11
Lower Respiratory Tract Infections
Acute exacerbation of COPD
NB consider whether antibiotic therapy is required at all for non-severe disease.
Indication
Drug(s)
Dose
Route Frequency Notes
st
Co-amoxiclav should
1 line
Amoxicillin
500mg
PO
TDS
or
Co-amoxiclav
625mg
PO
TDS
be used only if patient
has received
amoxicillin prior to
admission and there
is concern regarding
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Trust Policy
Penicillin
allergy
Doxycycline
200mg
(day 1)
then
100–
200mg
daily
PO
OD
antibiotic failure, or
hospital acquired
infection.
Review previous
microbiology
Dose depends on size
of patient and severity
of infection. If
doxycycline
contraindicated
contact
microbiologist/ID for
advice.
Bronchiectasis
patients: please refer
to Respiratory team
Community Acquired Pneumonia
Indication
1st line
CURB65 =
0/1
Drug(s)
Amoxicillin
CURB65 = 2
CURB > 3
Penicillin
allergy
If atypical
pneumonia
suspected
If Hospitalacquired
Penicillin
allergy
Dose
500mg
Route
PO/IV
Frequency
TDS
Amoxicillin
AND
Clarithromycin
500mg
PO/IV
TDS
500mg
PO/IV
BD
Co-amoxiclav
AND
Clarithromycin
Non-severe:
Clarithromycin (see
above)
1.2g
IV
TDS
500mg
IV
BD
1g
IV
TDS
500mg
PO/IV
BD
or
Severe:
Meropenem
AND
Clarithromycin (see
above)
ADD
Clarithromycin
Notes
IV if patient NBM
or dictated by
CURB score (see
BTS guidelines),
change to oral
later if possible.
NB review
previous
microbiology
Non-severe:
Co-amoxiclav (see
above)
Severe:
Tazocin
4.5g
Non-severe:
Doxycycline
200 mg
IV
TDS
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Trust Policy
day 1
followed
by 100 mg
PO
OD
Severe:
Meropenem
1g
IV
TDS
AND
Clarithromycin
500 mg
IV
BD
OR
Co-trimoxazole
960 mg
PO
BD
(septrin)
A 5 day course is recommended for most respiratory tract infections with clinical review
prior to completion. If in doubt contact a Consultant Microbiologist/ID physician
If PVL toxin producing Staph aureus is suspected or identified as the cause of infection, follow
the HPA guidance regarding management
Aspiration Pneumonia
Indication
Drug(s)
Dose
Route
Frequen
cy
TDS
Aspiration
pneumonia
Co-amoxiclav
1.2g
IV
Penicillin
allergy
Gentamicin
5mg/kg
(max 560mg
dose)
IV
OD
regimen
400mg
PO
TDS
Notes
For in-patient
aspiration (>48 hrs
after admission)
use: Tazocin (see
above).
The addition of
metronidazole is
NOT required
AND
Metronidazole
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500mg IV TDS if
NBM
Trust Policy
6.12
Clostridium Difficile
See WAHT-INF-016 (via Document Finder on the intranet)
6.13
Endocarditis
Prophylaxis of Endocarditis
See table in section 5.1 of the current BNF. NB: refer to NICE guidance for recommendations of
patient groups requiring endocarditis prophylaxis:
http:www.nice.org.uk/nicemedia/pdf/CG64NICEguidance.pdf. In certain circumstances the
cardiologists may also recommend prophylaxis for particular groups of high risk patients according
to individual risk assessment.
Treatment of Endocarditis
All suspect and confirmed cases should be referred to a consultant cardiologist. In all confirmed
cases, treatment will be indicated for at least 2 weeks, with regular review in consultation with a
medical microbiologist/ID physician.
See intranet for guidance on Gentamicin dosing and monitoring WAHT-PHA-004
Guidelines are drawn from BSAC recommendations for adults with endocarditis (JAC May 2012,
vol 67(5): 1304.(JAC Feb 2012, vol 67(2): 269-89).
Indication
Empirical
treatment
Native valve
indolent
presentation:
Native valve
acute onset:
Drug(s)
Amoxicillin
Dose
2g
Route
IV
Frequency
6 times a
day
AND
Gentamicin
Vancomycin
1 mg/Kg
IV
BD
1g
IV
BD
Meropenem
2g
IV
TDS
Vancomycin
1g
IV
BD
1 mg/kg
IV
BD
300-600 mg
IV
BD
AND
Prosthetic
valve:
AND
Gentamicin
AND
Rifampicin
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Notes
Discuss with
microbiologi
st/ID
physician.
Therapy
may require
amendment
based on
microbiology
results.
Trust Policy
The above guidance is empirical and covers the more common causes of endocarditis.
Take three sets of blood cultures and the medical microbiologists will give full guidance if treatment
needs to differ from the above.
NB: Gentamicin therapy is often NOT required for the full duration of antibiotic therapy.
Remember: Early referral of all cases of confirmed/suspected endocarditis to cardiology or ID is
recommended.
6.14
Treatment of Suspected Meningitis
The treatments given below cover both common causes of meningitis (Neisseria meningitidis and
Streptococcus pneumoniae). Very occasionally, other organisms can be responsible. In immunocompromised patients, Listeria monocytogenes or Cryptococcus neoformans are possibilities.
These organisms are usually readily detected on CSF microscopy; please discuss any unusual
patient factors with a medical microbiologist. Rarely, meningitis can be caused by Mycobacterium
tuberculosis. In the appropriate clinical context Herpes simplex encephalitis should be considered
in the differential diagnosis.
See also NICE guideline 102.
Early referral to the ID team is recommended. The medical microbiologist or infectious diseases
physician will also give treatment guidance for more unusual cases of meningitis.
Indication
Empirical
treatment
Drug(s)
Cefotaxime
Dose
2g
Route
IV
Frequency
QDS (TDS
when
improving)
2g
IV
QDS
25 mg/kg
IV
QDS
2g
IV
4 Hourly
500mg
PO
Single dose
AND
Amoxicillin (if >55 yrs old
or immunocompromised)
Penicillin
allergy
As above – If
documented severe
reaction or anaphylaxis
with penicillin or
cephalosporin:
Chloramphenicol
Discuss with
Microbiologist/ID
Amoxicillin
Listeria
meningitis
To clear
Ciprofloxacin
nasopharyng
eal carriage
(of
meningococci
)
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Notes
NB: increased C
difficile risk:
For proven
bacterial
meningitis
treatment must be
given IV for the
whole course.
Refer patient to ID
physician
Reduce dose as
soon as clinically
indicated.
Measure plasma
concentrations in
elderly and hepatic
impairment (BNF
5.1.7)
Can be given as
soon as patient
eating.
If ciprofloxacin
contra-indicated
discuss with
Medical
Microbiologist ( NB
ciprofloxacin is
recommended by
Trust Policy
the HPA for all
patients, including
children and
pregnant women)
Give antibiotics promptly – delay costs lives
In any case of suspected meningococcal disease, inform the Health Protection Unit (HPU),
contactable via switchboard in-hours. They will advise on antibiotic prophylaxis of
household and other contacts. Out-of-hours contact Public Health on-call physician via
Switchboard (via First Response).
6.15
Septic Arthritis and Osteomyelitis
Indication
Empirical
treatment
Drug(s)
Flucloxacillin
Dose
1g
Route
IV
Frequency
QDS
500mg
PO
TDS
AND
Sodium fusidate
Penicillin
allergy or
suspected
MRSA
6.16
Notes
Take blood
cultures and joint
aspirate
- review antibiotic
therapy when
culture results
available.
substitute Vancomycin
for Flucloxacillin
Antibiotic Use in Accident and Emergency
Skin and Soft Tissue Infection
Indication
Suspected
staphylococcal or
streptococcal
infection, e.g.
cellulitis,
lymphangitis,
abscesses, ingrowing toe nails
Drug(s)
Flucloxacillin
Dose
500mg –
1g
Route
PO
Frequency
QDS
Notes
Flucloxacillin
covers both
staphylococca
l and
streptococcal
infection
See also A/E Ambulatory Management of limb cellulitis policy (WAHT-A&E-034) for escalation
management
Prophylaxis for
dirty wounds, e.g.
soil or faecal
contamination
Human Bites (all)
and dog and cat
bites and
scratches
Co-amoxiclav
625mg
PO
TDS
Co-amoxiclav
625mg
PO
TDS
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Trust Policy
For all above indications for penicillin allergic patients use Clarithromycin, except for human and
animal bites in adults and children over 12, when Doxycycline and Metronidazole should be
prescribed; for children under 12 yrs Clarithromycin and Metronidazole should be prescribed.
Compound Fractures
Indication
Drug(s)
Minor fractures, e.g. Flucloxacillin
crush injuries to
fingertip or minor
wound over
significant fracture
Penicillin allergy
Clindamycin
Dose
500mg –
1g
Route
PO
Frequency
QDS
Notes
450mg
PO
QDS
Major compound
fractures, i.e. likely
to require surgical
intervention
Co-amoxiclav
AND
Gentamicin
1.2g
IV
TDS
5mg/kg
(max
560mg
dose)
IV
OD regimen
NB: increased
C difficile risk
Give IV
antibiotics as
soon as
possible and
clean and cover
wound
Major compound
fractures, i.e. likely
to require surgical
intervention and
severe penicillin
allergy, i.e.
anaphylaxis
Discuss with
microbiologist (see notes
above)
Dental Abscesses
Indication
Dental abscess
Drug(s)
Amoxicillin
Dose
500mg
Route
PO
Frequency
TDS
Penicillin allergy
Clarithromycin
500mg
PO
BD
Notes
Add
metronidazole
400mg TDS if
severe
Tonsillitis
Indication
Tonsillitis
Penicillin allergy
Drug(s)
Penicillin V
Clarithromycin
Dose
500mg
500mg
Route
PO
PO
Frequency
QDS
BD
Notes
10 days
10 days
Drug(s)
Amoxicillin
Clarithromycin
Dose
500mg
500mg
Route
PO
PO
Frequency
TDS
BD
Notes
7 days
7 days
Otitis Media
Indication
Otitis media
Penicillin allergy
Lower Respiratory Tract Infection
Indication
Acute
Drug(s)
Amoxicillin
Dose
500mg
Route
PO
Frequency
TDS
Worcestershire Secondary Care Adult Antibiotic Prescribing Policy
WAHT-PHA-001
Version 7.1
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Notes
Consider co-
Trust Policy
exacerbation of
chronic bronchitis
or
Doxycycline
Pneumonia (if well
enough to go
home)
Pneumonia –
penicillin allergy
PO
OD
Amoxicillin
200mg (day
1) then 100200mg daily
500mg
PO
TDS
Clarithromycin
500mg
PO/IV
BD
amoxiclav if
patient has
already taken
st
1 line agents
Consider coamoxiclav if
patient has
already taken
st
1 line agents
Pelvic Inflammatory Disease – refer to Intranet Trust guideline WAHT-GYN-008
Suspected Meningitis – see Treatment of Suspected Meningitis (above)
Urinary Tract Infection
Indication
1st line
Drug(s)
Trimethoprim
If Trimethoprim
Nitrofurantoin
tried with no
success and no
cultures or if
patient pregnant
If treatment with
Co-amoxiclav
trimethoprim or
nitrofurantoin failed,
or symptoms more
severe
Dose
200mg
Route
PO
Frequency
BD
Notes
3 days for
women, 7
days for men
50mg
PO
QDS
625 mg
PO
TDS
3 days for
women, 7
days for men
and pregnant
women
3 days for
women, 7
days for men
Worcestershire Secondary Care Adult Antibiotic Prescribing Policy
WAHT-PHA-001
Version 7.1
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Cefalexin may
also be used
in pregnancy
(7 days)
Trust Policy
6.17 Factsheet on Splenectomy And Infection
NB Information and an alert card (‘I have no functioning spleen’) are available from the Pharmacy
departments.





If you have had your spleen removed, then you are more likely to get some types of
infection. These infections can develop very rapidly. An early diagnosis and
effective treatment can be life-saving.
Ask your doctor about pneumococcal vaccination, meningitis and Hib vaccines.
Consult your doctor immediately if you develop a feverish illness.
If you are having a surgical or dental procedure, always make sure that your doctor
or dentist knows that you have no spleen. They may want to give you antibiotics
beforehand.
Please consult your doctor before going abroad or undertaking any unusual leisure
pursuits. You may need to take preventive antibiotics or other special precautions.
The Spleen
The spleen plays a part in the body’s resistance to infection (immunity). It is situated in the upper
left-hand side of the abdomen partly protected by the bottom of the rib cage. The spleen may be
removed or stop functioning normally for a number of reasons. If it is injured in an accident, it may
have to be removed (splenectomy) to control the bleeding. In a range of diseases of blood cells
(from some forms of leukaemia to sickle cell disease) the spleen may cease to function properly. If
it becomes uncomfortably large as a consequence of such a disease, removal may be the best
option. Bone marrow transplant also interferes with the normal splenic function.
There was a time when the spleen was thought to be unnecessary to health (like the appendix),
but it is now known that people without spleens have a greater risk of severe infection than people
with normal spleens. Therefore doctors try not to remove the spleen unless a splenectomy is
either life-saving after injury, or very important in the treatment of a disease that involves the
spleen.
What if the spleen has been removed or ceases to function?
The main problem is the risk of severe infection. The risk depends on age (children have a higher
risk than adults) and on whether there is another disease present or not. The commonest type of
infection is by a bacterium, Streptococcus pneumoniae or the “pneumococcus”, which is, as its
name suggests a cause of pneumonia amongst other diseases. Other bacteria, which can cause
infections, are Haemophilus influenzae type b and Neisseria meningitidis both of which can cause
meningitis amongst other diseases. In people without spleens, these bacteria are not filtered out of
the bloodstream as effectively as they should be, so the infection can sometimes progress to
septicaemia, an infection of the blood. Unfortunately, this can occasionally be fatal. The lack of a
spleen also makes people more susceptible to attacks of malaria.
How great is the risk of infection after splenectomy
The risk of severe infection in healthy people with spleens is very low; the chances of dying from
severe infection are about the same as the chances of dying from a home accident – 1 in 30,000
per year. The risk to a person without a functioning spleen varies from eight times higher (an adult
who has their spleen removed because of injury), to fifty times higher (children without spleens),
than the general population. This is still a low risk, being of the same order as being killed in a
road accident. Another way of expressing this risk is that if 100 people without spleens were
followed up for 10 years, between one and five of them would have severe infection within that
period of time.
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WAHT-PHA-001
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Trust Policy
How long does the risk of infection last after splenectomy?
The highest risk of infection occurs after splenectomy in childhood and the first two years after
splenectomy in adults. However, the risk does not end here and medical journals have repeatedly
published accounts of severe infection in adults up to ten years later. It is likely that there is some
small increased risk life-long.
In patients who have an underlying disorder of the immune system, the increased risk of infection
is life-long.
What can be done to reduce the risk?
There are several things that you and your doctors can do to minimise these risks.
Vaccination against infection
Fortunately there are effective vaccines against the important pneumococcal infection. For
individuals aged over 5 years the vaccine is an injection of purified bacterial substances derived
from the most common types of the pneumococcus. The vaccine has been used both here and in
America for many years and has an excellent record of safety. A different, more recently
developed type of vaccine is used initially for children aged under 5 years; from 2006, this vaccine
is also given to routinely to all babies at the time of their other childhood immunisations. Both
vaccines are now officially recommended by the Department of Health for patients without
functioning spleens. A booster dose of vaccine is recommended every 5 years; a blood test prior
to revaccination is not considered necessary.
There is also an effective vaccine against the second commonest cause of serious infection in
splenectomised patients. Haemophilus influenzae type b (Hib). Hib vaccine is given routinely to
babies at the time of their other childhood immunisations and has been used safely since the early
1990s.
An effective, safe, vaccine is also available against an important cause of meningitis, Neisseria
meningitidis (serogroup C). This vaccine is given routinely to all babies at the time of their other
childhood immunisations.
From 2006 onwards, protection against Hib and Meningitis C will be offered as a combined (2 in 1)
vaccine; 2 doses are given to patients without functioning spleens, 2 months apart.
Influenza vaccination is recommended yearly for patients without a functioning spleen as this may
protect against secondary bacterial chest infections.
Vaccines are best given at least two weeks before splenectomy if possible as this gives the best
protection. If this is not practicable, vaccines can be given after the operation before you leave
hospital. However, if you need immunosuppressive chemotherapy or radiotherapy to treat your
illness, vaccination should be left until at least three months after this has finished (you can take
antibiotics in the meantime; see below).
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Trust Policy
Summary table on use of conjugate and polysaccharide vaccines in asplenia
patients
(Adapted from Immunisation against Infectious Disease, Chapter 7)
Following emergency spenectomy it is recommended to wait two weeks before immunisation.
Suggested schedule for immunisation with conjugate vaccines in individuals with splenic
dysfunction and immunosuppression
Age at which asplenia or
splenic dysfunction or
immunosuppression is
acquired.
Vaccination schedule.
Where possible, vaccination course should ideally be started at least two
weeks before surgery or commencement of immunosuppressive treatment. If
not possible, see advice in pneumo chapter.
Month 0
Under two years
(unvaccinated or partially
vaccinated).
Month 2
Routine immunisation schedule should be followed but MenC vaccine should
be replaced with the MenACWY conjugate vaccine.
Booster dose of
Over one year and under two Hib/MenC vaccine.
years (fully vaccinated).
Booster dose of PCV.
Single dose of
MenACWY conjugate
vaccine.
Single dose of PPV.
Over two to under five years
(fully vaccinated including
booster).
Booster dose of
Hib/MenC vaccine.
Over two to under five years
(unvaccinated or partially
vaccinated).
First dose of Hib/MenC
vaccine.
Second dose of
Hib/MenC vaccine.
First dose of PCV.
Second dose of PCV.
Five years and older (and
previously vaccinated with
Hib, MenC, PCV vaccines).
Booster dose of
Hib/MenC vaccine.
Single dose of
MenACWY conjugate
vaccine.
Five years and older
(unvaccinated)
Month 4
Booster dose of PCV.
Single dose of PPV.
First dose of Hib/MenC
vaccine.
Single dose of PPV.
Single dose of
MenACWY conjugate
vaccine.
Second dose of
Hib/MenC vaccine.
None.
Single dose of PPV.
Single dose of
MenACWY conjugate
vaccine.
Single dose of
MenACWY conjugate
vaccine.
PCV – pneumococcal conjugate vaccine. PPV – pneumococcal polysaccharide vaccine
Worcestershire Secondary Care Adult Antibiotic Prescribing Policy
WAHT-PHA-001
Version 7.1
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Trust Policy
Antibiotics
Prophylactic antibiotics
Lifelong prophylactic antibiotics should be offered to all patients, (and should be taken for at least
the first two years after splenectomy), for all children having splenectomies up to the age of 16,
and where a patient’s illness means they have underlying impaired immune function.
ANTIBIOTIC PROPHYLAXIS
Children under 5 yrs old
Phenoxymethylpenicillin
125mg
Children 5 – 16
Phenoxymethylpenicillin
250mg
Adult
Amoxicillin
12 hourly
12 hourly
250mg
Daily
Alternative in penicillin allergy:
Children under 2
Erythromycin (base)
125mg
Children 2 – 8
Erythromycin (base)
250mg
Erythromycin (base)
250 – 500mg
Adults and Children over 8
Daily
Daily
Daily
Antibiotics in illness
If you become unwell with symptoms such as, a raised temperature, a severe sore throat,
feverishness, a headache with drowsiness, severe abdominal pain or a rash, then you should
begin a higher dose of antibiotic from a supply which you keep at home. This should be done
before you contact your doctor promptly. If you take penicillin or amoxicillin regularly then start a
course of amoxicillin. If you take erythromycin then increase the dose of this antibiotic.
ANTIBIOTICS TO TAKE WHEN ILL
Amoxicillin
Children under 1 year
Children aged 1 – 4 yrs
Children 5 – 14 yrs
Adult
Erythromycin
Children under 2 yrs
Children aged 2-8 yrs
Adult & Children over 8 years
62.5mg
125mg
250mg
0.5-1g
8 hourly by mouth
8 hourly by mouth
8 hourly by mouth
8 hourly by mouth
12.5mg/kg/day in 4 divided doses
250mg
6 hourly by mouth
0.5-1g
6 hourly by mouth
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WAHT-PHA-001
Version 7.1
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Trust Policy
6.18 Meticillin-Resistant Staph Aureus – (Mrsa)
Please see Trust policy WAHT-INF-003, Protocol for the management of Meticillin Resistant
Staphylococcus aureus (MRSA) which includes:

Management of patients with MRSA

Treatment regimes

Management of staff and MRSA
7.
Financial risk assessment
The financial risk assessment associated with policy is attached as Appendix 4. The
financial risks associated with this Policy include ensuring that there are sufficient expert
resources to deliver the educational elements of policy dissemination and monitoring and
audit of compliance.
8.
Consultation
This policy has been developed in consultation with Consultant Microbiologists, Consultant ID
Physicians, the Trust’s Antimicrobial Pharmacist, other Pharmacy staff and has been
circulated to all Clinical Directors for comment.
9.
Approval process
The policy has been developed by Microbiologists, ID physicians and Pharmacy staff, and
has been subject to consultation with clinical directorates. The policy has been approved by
the Medicines Safety Committee.
10.
Implementation arrangements
The policy will be implemented immediately upon approval.
11.
Dissemination process
The policy will be placed in the Trust’s Document library on the Intranet and will be publicised
through educational sessions (formal and ad hoc), induction programmes and via the
Pharmacy Department. Empirical therapy ‘credit cards’ are also issues to all relevant staff.
12.
Training and awareness
Awareness of this Policy will be raised throughout the Trust. It will be included in all
induction training, and teaching delivered by the Consultant Microbiologists and Infectious
Disease Physicians.
13.
Monitoring and compliance
Compliance will be monitored via:
;
 Regular review of antimicrobial prescriptions by ward based pharmacists
 Daily clinical ward rounds by Consultant Medical Microbiologists based on laboratory
surveillance and clinical request, with ad hoc further surveillance in specified areas
 Weekly Infection MDT meetings between Microbiologists and ID physicians
 Regular review of antimicrobial usage reported to TIPCC by the Trust’s Antimicrobial
Pharmacist
 An annual audit programme agreed and co-ordinated through the Antimicrobial
Stewardship Group, reporting to TIPCC
 Antibiotic prescribing advice recorded in Microbiology Clinical Record, which is
auditable.
 Root cause analysis of infection related SUI
Worcestershire Secondary Care Adult Antibiotic Prescribing Policy
WAHT-PHA-001
Version 7.1
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Trust Policy
14.
Development of the Policy
This policy will be reviewed in 2 years or earlier in the light of any significant changes
required as a result of developments in good practice, changing epidemiology, external
recommendations, etc., to ensure its continuing relevance and effectiveness.
References:
Code:


British National Formulary issue 59 (March 2010)
National Institute for Health and Clinical Excellence: Prophylaxis against infective
endocarditis, Clinical Guideline 64 (March 2008)
 Scottish Intercollegiate Guidelines Network (SIGN)
 Guidelines for the antibiotic treatment of endocarditis in adults: report of the working
party of the British Society for the Antimicrobial Therapy. JAC, Dec 2004, vol 54(6); 971981.
 BTS guidelines on management of community acquired pneumonia in adults: update
2009. Thorax 2009; 64(suppl3) iii1-iii55.
Hyperlinks to other references are contained within the policy.
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WAHT-PHA-001
Version 7.1
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Trust Policy
Supporting Document one - Equality Impact Assessment Tool
Yes/No
1.
Comments
Does the policy/guidance affect one
group less or more favourably than
another on the basis of:
 Race
No
 Ethnic origins (including gypsies and
No
travellers)
 Nationality
No
 Gender
No
 Culture
No
 Religion or belief
No
 Sexual orientation including lesbian,
No
gay and bisexual people
 Age
No
2.
Is there any evidence that some groups
are affected differently?
No
3.
If you have identified potential
discrimination, are any exceptions
valid, legal and/or justifiable?
n/a
4.
Is the impact of the policy/guidance
likely to be negative?
No
5.
If so can the impact be avoided?
n/a
6.
What alternatives are there to achieving
the policy/guidance without the impact?
n/a
7.
Can we reduce the impact by taking
different action?
No
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WAHT-PHA-001
Version 7.1
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Trust Policy
Supporting Document 2 - Financial Risk Assessment
Title of document:
Yes/No
1.
Does the implementation of this document require any
additional Capital resources
No
2.
Does the implementation of this document require additional
revenue
Does the implementation of this document require additional
manpower
No
3.
YES
4.
Does the implementation of this document release any
manpower costs through a change in practice
No
5.
Are there additional staff training costs associated with
implementing this document which cannot be delivered
through current training programmes or allocated training
times for staff
No
If the response to any of the above is yes, please complete a business case and which is
signed by your Finance Manager and Directorate Manager before progressing to the
relevant committee for approval
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WAHT-PHA-001
Version 7.1
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Trust Policy
Appendix 1
Plan for Dissemination of Key Document
Title of
document:
WORCESTERSHIRE SECONDARY CARE ADULT ANTIBIOTIC
PRESCRIBING POLICY
Date finalised:
Dissemination lead:
Print name and
contact details
Previous
document already
being used?
Yes
(Please delete as
appropriate)
If yes, in what
format and
where?
Trust Policy document held on intranet under Pharmacy Library
Proposed action
to retrieve out-ofdate copies of the
document:
Delete existing policy and replace with revised policy
To be
disseminated to:
How will it be
disseminated, who
will do it and when?
All appropriate staff Publication on
intranet
Issue of antimicrobial
‘credit cards’
Paper
Comments
or
Electronic
Electronic
Also promotion via formal and
ad hoc educational sessions
paper
Managers
Publication on intranet electronic
Trust Board
Publication on intranet electronic
Managers
Publication on intranet electronic
Dissemination Record - to be used once document is approved.
Date put on register /
library of procedural
documents
Disseminated to:
(either directly or
via meetings, etc.)
Date due to be
reviewed
Format (i.e.
paper or
electronic)
Date
Disseminated
No. of
Copies
Sent
Contact Details /
Comments
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WAHT-PHA-001
Version 7.1
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