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Aneurin Bevan Health Board

Adult Antibiotic Guidelines

Secondary Care

Please note: The Antibiotic Prophylaxis Guideline full document is available on the intranet N.B. Staff should be discouraged from printing this document. This is to

avoid the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the document.

Status: Issue 3 Issue date: 4 March 2013 Approved by: Clinical Standards & Policy Group Review by date: 4 March 2016 Owner: Antimicrobial Working Group Policy Number: ABHB/Clinical/0008

Aneurin Bevan Health Board ABHB/Clinical/0008Adult Antibiotic Guidelines Secondary Care Owner: Antibiotic Working Group

Status: Issue 3 Issue date: 4 March 2013 Approved by: Clinical Standards & Policy Group Review by date: 4 March 2016

Page 1 of 26

1 Executive Summary

These guidelines provide an overview of recommended antibiotics for empirical use within the organisation.

1.1 Scope of guidelines

These guidelines apply to adult in-patients prescribed antibiotics.

2 Aims

These guidelines aim to provide prescribers with guidance to ensure that empiric antibiotic prescribing is appropriate and cost effective. 3 Policy Statement These guidelines aim to improve the quality of prescribing of antibiotics within the organisation. 4 Responsibilities It is the prescriber’s responsibility to check appropriateness of agents used taking into account co-existing conditions or medication. All prescribers and pharmacists have a responsibility to ensure empiric antibiotic prescribing is guided by the health board’s antibiotic guidelines. 5 Training No formal training is required on these guidelines. New members of medical and pharmacy staff and other prescribers within the organisation will be advised on how to access the guidelines on their induction. 6 Audit The guidelines will be audited by the antibiotic working group or pharmacy annually. The results will be fed back to the antibiotic working group, which will agree an appropriate strategy dependant on audit results. 7 Further Information Further information can be obtained from the Antimicrobial Pharmacist based in the pharmacy department.



Page 2 of 26

Contents Condition

1 Community-acquired pneumonia 2 Infective exacerbations of COPD 2 Infective exacerbation of asthma 3 Aspiration pneumonia 3 Hospital-acquired pneumonia 4 Clostridium difficile-associated diarrhoea 5 Intra-abdominal infections (cholecystitis, peritonitis,

hepato-bilary) 6 Hepatic abscess 7 Spontaneous bacterial peritonitis 8 Gastroenteritis 9 Cellulitis 10 Diabetic foot ulcer 11 Infected human or animal bite 12 Breast – lactational mastitis 13 Non lactational breast sepsis 14 Suspected necrotising fasciitis 15 Urinary tract infections – Community acquired,

uncomplicated 16 Urinary tract infections – Hospital-acquired 17 Pyelonephritis (includes patients with an indwelling

catheter) 18 Acute bacterial prostatitis 19 Epididymo-orchitis 20 Meningitis 21 Endocarditis 22 Sepsis (unknown origin) 23 Neutropenic sepsis 24 Osteomyelitis 24 Septic arthritis 25 Prosthetic joint infection 26 Open fracture 26 Dirty wound 27 Aminoglycosides & Vancomycin dosing information 28 Antimicrobial prophylaxis summary 29 Antimicrobial dosing guidelines in adults with renal

impairment and failure 30 Gentamicin administration charts



Page 3 of 26

Antibiotic Prescribing These guidelines have been revised in response to concerns nationally and locally over the rates of Clostridium difficile infection. Cephalosporins and fluoroquinolones have been particularly associated with a higher risk of C. difficile, but all broad-spectrum antibiotics are potentially hazardous for this infection. The routine use of cefuroxime, cefalexin and ciprofloxacin is not recommended. The use of these antibiotics should be limited to treating conditions where there are no alternatives that provide adequate cover or when their use is explicitly recommended in this guide.

Whenever possible, relevant specimens for culture must be taken from in-patients

before starting antibiotics.

• ALL antibiotics prescribed on a chart must have the intended DURATION or date for

review specified in the special instructions section of the drug chart. • Antibiotics should be given for the complete course prescribed and doses should not

be omitted. • Restricted antibiotics should be approved by microbiology before prescribing (See

below). • Oral antibiotics prescribed for 5 days will be stopped according to the criteria in the

antibiotic automatic stop policy unless the duration is specified. • All recommended doses are for ADULT in-patients with normal renal and liver

function.

Restricted antimicrobials

The following antimicrobials are restricted within the organisation according to the restricted antimicrobial policy. If they are prescribed for an indication or patient group that is not listed in the exemptions in the restricted antimicrobial policy please contact microbiology to obtain approval for their use.

Amphotericin, Caspofungin, Ciprofloxacin (IV), Doripenem, Ertapenem, Fidaxomicin*, Fluconazole (IV), Imipenem/Cilastatin, Levofloxacin, Linezolid,

Meropenem, Pivmecillinam, Teicoplanin, Tigecycline, Voriconazole

The restricted antimicrobial policy does NOT apply to:

paediatric, haematology, critical care or neutropenic patients * Fidaxomicin requires approval by consultant microbiologist in all cases



Page 4 of 26

1. Community-acquired pneumonia

Antibiotic Treatment

Advised Total Duration

Alternatives for Penicillin allergic patients (patient has had an anaphylactic reaction)

Mild (CURB-65 < 1)

Amoxicillin PO 500mg tds

1g tds plus

clarithromycin PO 500mg bd

Or if oral administration not possible:

Moderate (CURB-65 = 2)

Amoxicillin PO 500mg to

URB-65 >

Amoxicillin IV 500mg tds plus

clarithromycin IV 500mg bd

Severe (C 3)

clarithromycin IV/PO 500mg bd. Review IV need

significant co-

Benzylpenicillin IV 1.2g qds plus

daily.

If life-threatening infection, morbidities, risk of Gram negative infection or care home resident:

Co-amoxiclav IV 1.2g tds and

00mg bd. Review IV need daily.

7 days

7 days

days

to 14 to 21 days if

n Clarithromycin IV/PO 5

7 to 10

May extend

Staphylococcal or Gram-neg

infectio

Mild (CURB-65 < 1)

Doxycycline PO 200mg loading dose then PO 100mg od, or clarithromycin PO 500mg bd

not

Moderate (CURB-65 = 2)

Doxycycline PO 200mg loading dose then PO 100mg od, or clarithromycin PO 500mgbd

If oral administration is possible and cephalosporins are considered satisfactory having considered the nature of the allergy:

Cefuroxime IV 1.5g tds plus

clarithromycin IV 500mg bd

In severe anaphylaxis: Levofloxacin IV 500mg bd

Severe (CURB-65 > 3)

tact microbiology

Con



Page 5 of 26




Comments/References ALWAYS check and record the CURB-65 score

Recent onset Confusion

Urea >7

Resp Rate>30

BP systolic <90 or diastolic <60

Age>65 years

BTS Guidelines: Thorax 2009; v64 (Suppl III); iii1-iii55. doi:10.1136/thx.2009.121434

2. and a withpn

Infective exacerbations of COPD asthm no signs of eumonia on X-ray




Amoxicillin PO 500mg tds Mild or

n: 5 days Severe

acerbation: 7 days

Doxycycline PO 200mg stat Moderate exacerbatio

ex

then 100mg od



Page 6 of 26

. Hospital-acquired pneumonia and aspiration pneumonia

spiration pneumonia

3 A




IV/PO (IV 1.2g tds/ PO 625mg tds) does not respond in 24

ys Co-amoxiclavContact microbiology if patient hours

7 da Doxycycline PO 200mg stat hen doxycycline PO 100mg t

bd Hospital-acquired pneumonia that presents < 5 days after admrec

ission, and has not eived antibiotics in last 10 days



Alternatives for Penicillin allergic patients (patient has had an anaphylactic reaction) Doxycycline PO 200Co-amoxiclav IV/PO (IV 1.2g tds/ PO 625mg tds)

Contact microbiology if patient does not respond in 24 hours

7 days mg stat then doxycycline PO 100mg bd

Hospital-acquired pneumonia that presents > 5days after admission, or has received ant

ibiotics within last 10 days, or has co-morbidities




Piperacillin/tazobactam IV 4.5g tds. Switch to oral Please discuss with treatment with co-amoxiclav PO 625mg tds or

sensitivities microbiology

according to culture and Comments/References Always review previous microbiology results. Check organisms and sensitivities – if known MRSA, Pseudomonas or multi-resistant gram organisms different a tibiotics likely to bn e required.. Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy J. Antimicrob. Chemother. 2008 62: 5-34



Page 7 of 26

rrhoea 4. Clostridium difficile-associated dia



Alternatives for Penicillin allergic patients (patient has had an anaphylactic reaction) Daily asses

Where possible STOP all other antibiotics and PPIs Non-severe

May be repeated once more if a non-severe relapse occurs.

episode occurs, switch to the ‘severe’ treatment course.

evere (WBC > 15x109/L, acutely rising creatinine and/or signs or symptoms of colitis) Vancomycin PO 125mg qds

symptoms not improving or relapse occurs, contact ultation on use of high-dose

.

0 days

ay be extended according to

sponse

sment is required.

worsening should not be deemed a treatment failure until received a few days of treatment.

ot

ded by astroenterologist.

Metronidazole PO 400mg tds

If symptoms not improving or are worsening, or a third

S

IfSurgical/GI/Micro for consvancomycin, tapering regimes, combination therapy or fidaxomicin

1

10 days, m

re

Symptoms not improving or

Anti-motility agents should nbe prescribed unless recommeng

Comments/References See also Clostridium difficile Policy (available on intranet) or Department of Health guidelines.

5. Intra-abdominal infections (cholecys riton )

titis, pe itis, hepato-bilary




Amoxicillin IV 1g tds and gentamicin IV 5mg/kg od (check levels) and metronidazole IV 500mg tds. Minimum of 5 days of IV treatment. Switch to oral treatment with co-amoxiclav PO 625mg tds. If gentamicin is contra-indicated use the following combination:- Piperacillin / tazobactam IV 4.5g tds and metronidazole IV 500mg tds

Teicoplanin IV 400mg 12 hourly for three doses then 400mg od and gentamicin IV 5mg/kg od (check levels) and metronidazole IV 500mg tds. Contact microbiology to discuss choice of oral treatment. If gentamicin is contra-indicated please contact microbiology

Comments/Reference See section 27 (aminoglycosides). Maximum dose for once daily Gentamicin is 560mg.

6. Hepatic abscess




Metronidazole IV 500mg tds and piperacillin / tazobactam IV 4.5g tds (switch to oral treatment with co-amoxiclav PO 625mg tds if sensitivities known otherwise contact microbiology)

Discuss with microbiology

Contact microbiology for advice



Page 8 of 26

us bacterial peritonitis 7. Spontaneo Treatment of spontaneous bacterial peritonitis




Piperacillin / tazobactam IV 4.5g tds Tigecycline IV 100mg stat then IV 50mg bd

Pro itis

phylaxis of spontaneous bacterial periton




Co-trimoxazole PO 960mg od for 5 days per week

Comments/References If there is an issue with compliance then co-trimoxazole ca POn be prescribed 960mg daily, without the two day break

8. Gastroenteritis



Alternatives for Penicillin allergic patients (patient has had an anaphylactic r

ended unless a particular cause, Clostridium difficile suspected

eaction)

Ae.g.

ntibiotics not recomm


Status: Issue 3 Issue date: 4 March 2013

9. Cellulitis Mild to moderate cellulitis


Approved by: Clinical Standards & Policy Group Review by date: 4 March 2016 Page 9 of 26

Advised Total Alternatives for Penicillin Duration) allergic patients (patient

has had an anaphylactic reaction)

for a witch to oral

treatment flucloxacillin PO 1g qds) ystemic toxicity and no

can be treated orally as an

Clarithromycin IV 500mg bd. Minimum of 4 days of intravenous therapy. Switch to ral clarithromycin PO 500mg

Flucloxacillin IV 1g qds (treat intravenouslyminimum of 48 hours before considering a s

NB Mild cases with no sncontrolled co-morbidities u

outpatient.

obd.

Comments/References Flucloxacillin alone provides adequate cover for streptococci in mild to moderate cases.

Cellulitis in a patient with risk factors for MRSA




Vancomycin IV (check levels)

Comments/Reference ycin dosing. See section 27 for vancom

Severe cellulitis

Comments/References Discontinue clindamycin immediately if diarrhoea or colitis develops.For classification of cellulitis see: Eron, L. J. 2003. The admission, discharge and oral switch decision processes in patients with skin and soft tissue infections. C nt Options in Infectious Diseases, urrent Treatme5: 245-250. See section 27 for vancomycin dosing.




and benzylpenicillin IV 2.4g 4-6 ourly

(see comments )

Flucloxacillin IV 1g qds h

Vancomycin IV (check levels) and clindamycin IV300-600mg bd-qds



Page 10 of 26

No drugs used here have signif d ns, and renal, liver, ocular or bone marrow toxicity. As gilancrequired. Go ng these infections. A s y is . No

10. Diabetic foot ulcer

te that many of the icant risks for siduous vi

iarrhoea, drug interactioe and monitoring is

od quality microbiological specimens are critical in managieparate detailed Diabetic Foot Care Pathwa also available

infection (Pedis Grade 1)


None – Use local dressings and regular podiatry

Mild infection (Pedis Grade 2) – mild infection, cellulitis <2 cm, infection confined to ski y unwell.

n and subcutaneous tissues and NOT systemicall




Flucloxacillin PO 1g qds adjust in light of Clindamycin PO 300mg qd

5 to 7 days, then

culture results and

Doxycycline PO 100mg bd or s

clinical response Comments/References Antimicrobial dressings are recommended, such as Inadine. Improve glycaemic control and non-weight bearing. Suitable to be treated in the community.

Mo edis Grade 3) – mild infecti litis streaking, deep tissue or bone infection and NO emical

derate infection (P on, celluT syst

>2 cm, lymphatic ly unwell.



Alternatives for Penicillin allergic patients or other contra-indications

c given within the last month:

ithin the last month:

suspected): Co-amoxiclav

loxacin e IV 500mg tds, with

switch to oral Linezolid PO 600mg bd plus Ciprofloxacin PO 500mg-750mg bd plus Metronidazole PO 400mg tds

Minimum 10 to 14 days Osteomyelitis minimum 4-6 weeks

Clindamycin PO 300mg-600mg qds Linezolid PO 600mg bd plus Ciprofloxacin PO 500mg-750mg bd plus Metronidazole PO 400mg tds Vancomycin IV (measure levels) plus Ciprofloxacin IV

oral Linezolid PO 600mg bd plus Ciprofloxacin PO 500mg-750mg bd plus Metronidazole PO 400mg tds

No antibiotiFlucloxacillin PO 1g qds plus (if anaerobes suspected) Metronidazole PO 400mg tds Antibiotic given wIf suitable for oral therapy: Either Clindamycin PO 300mg qds plus Ciprofloxacin PO 500mg bd; or (if Pseudomonas not suspected): Co-amoxiclav PO 625mg tds +/– amoxicillin 500mg PO tds If IV therapy required: Either: (if Pseudomonas not IV 1.2g tds, with switch to oral 625mg tds +/– amoxicillin 500mg tds after 5-7 days; Or: Vancomycin IV (measure vels) plus Ciprof

400mg tds plus Metronidazole IV 500mg tds, with switch to

leIV 400mg tds plus Metronidazol

Comments/References See section 27 for vancomycin dosing. Antimicrobial dressings, debridement, improved glucose control and non-weight bearing are also recommended.



Page 11 of 26

evere infection – SYSTEMICALLY UNWELL / SEPSIS SYNDROME (Pedis Grade 4) S




No antibiotic given within the last 90 days: Co-amoxiclav IV 1.2g tds plus Gentamicin IV 5mg/kg Antibiotic given within the last 90 days:

nal bactam

IV 4.5g tds (if ESBL coliforms never documented), or tds.

Oral switch when clinically appropriate: Ciprofloxacin PO 500mg-750mg bd plus

or Rifampicin* PO 300mg bd with one of: Doxycycline PO 100mg bd, or with Fusidic acid* PO 500mg tds, or with Trimethoprim PO 200mg bd

Minimum 10 to 14 days Osteomyelitis minimum 4-6 weeks

Vancomycin IV (substitute with Teicoplanin if renal function very poor) plus Ciprofloxacin IV 400mg bd plus Metronidazole IV 500 mg tds

Vancomycin IV (substitute with Teicoplanin if refunction very poor) plus either Piperacillin / tazo

plus Meropenem IV 1g

Metronidazole PO 400mg tds plus either Linezolid PO 600mg bd

Comments/References Take blood cultures and cultures from deep curettage or debridement tissue rather than superficial swabs. Adjust antibiotic regime based on culture results. * Need for hepatic monitoring. Do not use Rifampicin or Fu one forsidic acid al staphylococcal therapy as there is a high risk of resistance development. See section 27 (aminoglycosides and vancomycin) and section 29 (other drug dose adjustments. s) for renalMaximum dose for once daily Gentamicin is 560mg.

iabetic foot ulcers with suspected or proven MRSA D




eck levels) or (if renal function y poor) Teicoplanin IV/IM 400mg od after 3 doses 12

hours apart

d: r Fusidic acid* PO 500mg

tds (check LFTs) Oral switch when clinically appropriate: either Doxycycline PO 100mg bd (possibly with Fusidic acid* PO 500mg tds if dual therapy required) or Linezolid PO 600mg bd or Rifampicin* 300mg PO bd plus one of: Doxycycline PO 100mg bd, or with Fusidic acid* PO 500mg tds, or with Trimethoprim PO 200mg bd

Add Vancomycin IV (chver

If MRSA osteomyelitis suspected, also adRifampicin* PO/IV 600mg bd o

Comments/References * Need for hepatic monitoring. Do not use Rifampicin or Fusidic acid alone for staphylococcal therapy as there is a high risk of resistance development. See section 27 (vancomycin).



Page 12 of 26

1. Infected human or animal bite 1



Alternatives for Penicillin allergic patients (patient has had an anaphylactic re

-amoxiclav PO 625mg tds Consult microbiology action)

Co

5 days

12

. Breast - lactational mastitis




outpatient PO 500mg qds) 00 bd Flucloxacillin IV/PO 1g qds (if mild and treated as 7 days Clarithromycin PO 5 mg

3. Non lactational breast sepsis 1




dose 1.2g tds/ PO dose 625mg 7 days Clarithromycin IV/PO 500mg bd and metronidazole IV/PO

tds/ PO 400mg tds)

Co-amoxiclav IV/PO (IV tds)

(IV 500mg

14. Suspected necrotising fasciitis



Alternatives for Penicillin allergic patients (patient has had an anaphylactic r eaction)

Discuss with surgeons and microbiology



Page 13 of 26

5. Urinary tract infections- Male and female community acquired (w symptoms)

1

ithout systemic



Alternatives

have had antibiotics within the last 3 onths, when the risk of a resistant organism is higher.

mg qds (see comments)

days ale: 7 days

1st Line: Trimethoprim po 200mg bd, unless elderly (over 65) orm 2nd Line: Nitrofurantoin PO 50

Female: 3M

Comments/References Nitrofurantoin is contra-indicated in patients with CrCl <20mL/min, and not generally recommended if CrCl <50 mL/min. Consider use of Co-amoxiclav or Pivmecillinam if Trimethoprim is also contra-indicated. Calculator for creatinine clearance can be found in the renal dose section (section 29) and on the Clinical Portal. If patients are showing systemic symptoms then treat as hospital-acquired urinary tract infection.

16. Hospital-acquired urinary tract infec

tion



Alternatives

t then antibiotic choice based

Gentamicin IV 5mg/kg staon urine sensitivities, available within 24 hours.

Comments/Reference If patient unable to have Gentamicin contact microbiology to discuss. See section 27 (aminoglycosides). Maximum dose for once daily Gentamicin is 560mg.

17. Pyelonephritis (includes patients with an indwelling catheter)




Co-amoxiclav IV/PO (IV dose 1.2g tds/ PO dose 625mg tds). Continue IV until temperature resolves. If no response after 24 hours or sepsis add gentamicin IV 5mg/kg od (check levels).

14 days Gentamicin IV 5mg/kg od (check levels) If patient unable to have gentamicin please contact microbiology to discuss. Once sensitivities are reported switch to oral antibiotics according to sensitivities.

Comments/References For patients with chronic urinary conditions please review previous sensitivities. Ensure all patients with a UTI are well hydrated. See section 27 (aminoglycosides). Maximum dose for once daily Gentamicin is 560mg..

18. Acute bacterial prostatitis




Ciprofloxacin PO 500mg bd 14 days More severe cases 2 – 4 weeks



Page 14 of 26

hitis in adults 19. Epididymo-orc




If risk of STD: Ceftriaxone 500mg IM single dose and doxycycline PO 100mg bd

14 days

Azithromycin 1g PO single dose p500mg bd

If STD not suspected: Ciprofloxacin PO 500mg bd

21 days

lus Ciprofloxacin PO

20. Menin

gitis




Ceftriaxone IV 2g bd

ss with microbiology

7-21 days For patients with other risk factors: >55 years, alcohol,

depending on organism

Consult microbiology

Pregnant - please discu

grown

Comments/References It is statutory requirement to notify the Health Protection c H or via Team (Publi ealth) on 01495 332219 ambulance control out of hours.



Page 15 of 26

1. Endocarditis

cornerstone of diagnosis and should be taken prior to starting treatment -acute presentation, three sets of blood cultures should be taken over 12

s prior to commencing antimicrobial therapy. In acute presentation k r apart and start antibiotics.

Ke lines for the diagnosis and madults. Journal of Antimicrobial Chemotherapy, 2012, p269- Na

2

lood cultures are a Bin all cases. In sub

ours from peripheral sitehta e two sets one hou

Reference: Guidey antibiotic treat v67, p

ent of endocarditis in 289.

tive Valve – indolent presentation




ptional) gentamicin IV icin levels)

Vancomycin IV and gentamicin IV 1mg/kg bd (check vancomycin &

micin levels)

Amoxicillin IV 2g 4 hourly and (o1mg/kg bd. (check gentam

gentaComments/Reference See section 27 (aminoglycosides & vancomycin dosing). The use of gentamicin is optional before culture results are available. If patient is stable, ideally wait for blood culture results.

ative Valve, severe shock but no risk factors for EnteroN

bacteriaceae, Pseudomonas.



Alte

Convanis co

rnatives

Vancomycin IV and gentamicin IV 1mg/kg bd check vancomycin and gentamicin levels) (

sult microbiology if comycin allergy or gentamicin ntraindicated

Comments/Reference See section 27 (aminoglycosides & vancomycin dosing).

at nterobacteriaceae, Pseudomonas. N ive Valve, severe shock with risk factors for E




Vancomycin IV and Meropenem IV 2g 8 hourly ‡ ls)

Consultant microbiology (check vancomycin leve Comments/Reference See section 27 (vancomycin dosing) ‡ See section 29 (meropenem in renal impairment).

Prosthetic valve endocarditis pending blood cultures or if negative blood cultures



Alternatives

Vancomycin IV and gentamicin IV 1mg/kg bd and rifampicin IV or PO 300mg-600mg bd (use the lower rifampicin dose if severe renal impairment) (check LFTs, vancomycin and gentamicin levels)

Consult microbiology if vancomycin allergy or gentamicin is contraindicated

Comments/References See section 27 (aminoglycosides & vancomycin dosing).

Patient with additional risk factors for staphylococcus (IV drug user, dialysis)



Alternatives

Vancomycin IV and gentamicin IV 80mg tds (If patient <60kg reduce dose to 60mg) (check vancomycin and gentamicin levels)

Consult microbiology if vancomycin allergy or gentamicin is contraindicated

Comments/References See section 27 (aminoglycosides & vancomycin dosing).



Page 16 of 26

Un

22. Sepsis

known origin




nd gentamicin IV 5mg/kg od

for dosing in renal impairment.

Contact microbiology Co-amoxiclav IV 1.2g tds a(monitor levels)

If patient is renally impaired (CrCl < 30mL/min): Piperacillin / tazobactam IV. Please refer to section 29

Comments/References If patient has neutropenic sepsis then refer to neutropenic sepsis guidelines. Blood cultures should be taken prior to first dose given and results should be thin 24 hours. reviewed wiSee section 27 (aminoglycosides). Maximum dose for once daily Gentamicin is 560mg.

Un story of ESBL coliform infection

known origin with hi




mg qds Tigecycline IV initially 100mg very 12

1st Line: Imipenem/cilastatin IV 500mg/500 stat then 50mg e

hours. Comments/References Take cultures prior to first dose. Review antibiotic choice once cultures are available.

32 . Neutropenic sepsis



Alternatives for Penicillin allergic patients (patient has had an anaphylactic reaction) Contact microbiology R

efer to Integrated Care Pathway –Neutropenic Fever



Page 17 of 26

4. Osteomyelitis and Septic arthritis 2




4-6 weeks Contact microbiology

Flucloxacillin IV 1-2g qds and sodium fusidate PO 500mg tds Commen ferences ts/ReConsider alternatives once cultures available

High risk patients (see comments) or confirmed Gram-negative infection




Contact microbiology Contact microbiology

Comments/References High risk cases: prostheses, immuno-compromised, diabetic, IVDU, catheter related bloodstream infection.

5. Prosthetic joint infection 2


Advised Total Duration (IV and oral)

Alternatives

Vancomycin IV (check levels) and rifampicin IV 300-k LFTs are normal)

Consult orthopaedic surgeon

600mg bd (chec Comments/References See section 27 (vancomycin dosing).

26. Open fracture or dirty wound




Co-amoxiclav IV/PO (IV dose 1.2g tds/ PO dose 625mg tds)

Consult medical microbiologist

Comment:: Give Tetanus prophylaxis. Infections often polymicrobial.



Page 18 of 26

f r dosing 27. Aminoglycosides & Vancomycin – Guidelines o Calculations required for determining ideal body weight and creatinine clearance: Ideal body weight: Males: IBW = 50kg + 0.9kg for every cm over 152cm

Females: IBW = 45.5kg + 0.9kg for every cm over 152cm If patient’s ac 0% mor Adjusted body weight = IBW + 0.4(Actual body weight – IBW)

reatinine clearance:

tual body weight is 3 e than IBW:

C

on a patient’s renal nction. This can be approximated by calculating the creatinine clearance

ears) x weight (kg) x (1.25 for men)

Aminoglycoside and vancomycin dosing is dependent fuusing the Cockcroft–Gault equation: Creatinine clearance (mL/min) = (140–age in y

Serum creatinine (micromoles per litre)

, ascites, cystic fibrosis and major urns (more than 20% of body).

Gen osing

renal ht e nearest 4 olicy

the table b w:

L/min)

>70 30-70 -30

Gentamicin The majority of patients should receive gentamicin once daily. Exclusion criteria for once daily dosing include: severe renal impairment, pregnancy and post-partum women, endocarditis, dialysisb

tamicin once daily dwith normalIn patients function give 5mg/kg idea

0mg increment. Neutl body ropenic p

weig(maximum of 560mg) to thexempt: states 6mg/kg od. Appropriate dosing is given in elo Creatinine clearance (m

10 5-10

Gentamicin 5mg/kg OD and monitor levels

3-5mg/kg OD and monitor levels

2-3mg/kg OD and monitor levels

2mg/kg every 48-72 hours according to levels



Page 19 of 26

easurement for once daily dosing: ll levels should be taken prior to next dose (pre-dose levels). Peak dose

ld be taken rior to the second dose. Sample creatinine should be checked every other

djust dose depending on gentamicin level as shown in table below.

Gentamicin

Pre-dose (mg/L) (Trough level)

Serum level mAlevels are not required. First level should be taken prior to the third dose at the latest unless the patient is acutely unwell where the level shoupday and increase frequency of levels if renal function worsens. If patient is renally stable and the dose was not altered then assay every 5-7 days. A

Once daily dosingIdeal range <1

Level too high Reduce frequency GentamicinTo be used

mu d si by patients excluded from once daily dosing

W l B eight) per day in divided doses, every 8 urs — ually mg ing do then g or mg every 8 to . Dos a m me

or multiple daily dosing: heck both pre-dose and post-dose levels after the third dose. If patient is

ken renal

on

ltiple aily do ng

Dose: 3 to 5mor 12 ho12 hours

g/kg IB use to ne

(Idea 120rest 40

ody Wloadg incre

se, nt.

80m 120

Serum level measurement fCrenally stable and no adjustments were required, assays should be taevery 3-5 days. Levels will need to be taken more regularly in impairment and in deteriorating patients. Adjust dose depending gentamicin level as shown in table below.

Gentamicin Multiple daily dosing

Pre-dose (mg/L) Prior to next dose

Post-dose (mg/L) 1hr after last dose

Ideal range (other than Streptococcal & S ndocarditis)

<2 5 – 10

taphylococcal eStreptococcal & S docarditis taphylococcal en

<1 3 – 5

L Reduce frequency Reduce dose evel too high Level too low Incr e ease dos



Page 20 of 26

for oral

Vancomycin These dosing guidelines are for intra-venous dosing. For information dosing in the treatment Clostridium difficile, please see section 4. Intravenous vancomycin: Initially, the size of dose is determined by the patient’s weight, and the frequency of dosing by the renal function. Doses should then be adjusted according to serum levels. Dilute vancomycin in 250mL of 0.9% sodium chloride given over 2 hours. 50–60kg patient: 750mg doses 0–80kg patient: 1g doses 6

Other weights: 15mg/kg to a max of 2g per dose. Creatinine clearance (mL/min)

>80 60-80 40-60 30-40 20-30 10-20 <10 or on

dialysisVancomycin osing

every every every every every every every dinterval hours hours hours hours hours hours

12 18 24 36 48 60 96 hours

Serum level measurement Levels are required for every patient before the third dose. If the patient is renally stable and no adjustments were required after the first level then ssays should be taken every 3 to 5 days. Levels need to be taken more a

regularly in renal impairment and in deteriorating patients. Adjust dose depending on vancomycin level as shown in table below. Peak

vels are not routinely required, but may be performed if there is concern a to thera

R iversity Health Board. Good Prescribing Guide. Prescribing Guidelines for Medical Staff. Sixth Edition. Januar


lebout clinical response py.

Vancomycin Pre-dose (mg/L) Prior to next dose

Ideal range for uncomplicated infections

10 – 15 20 – 40

Range for BacteraEndocarditis, O

emia, steomyelitis, s susceptible

s of MRSA

20 – 40 15 – 20

Pneumonia, les(VISA) strainLevel too high Reduce frequency Reduce dose Level too low Increase frequency

(max 12 hourly) ef: Cardiff and Vale Un

y 2011

Increase dose

Aneurin Bevan Health Board ABHB/Clinical/0008Secondary Care Adult Antibiotic Guidelines Owner: Antibiotic Working Group


Page 21 of 26

2 laxis8. Antimicrobial Prophy Summary Table P ntimicro uidelineinformation. MRSA – If a patient has been known to have MRSA colonisation or infection in the past, its pre-operative eradication and the additi nti-M is reco fo invasive p additio hylt co single dose of Teicoplanin 4 vised for adult nfuse s is a less practical alternative. It is intended that antibiotic pr a sin gh t tradition of 4 hours or more for some p upporting evidence is weak and this is no longer r he m stances. If during the procedure it is appar that e oappropriate to extend the prop a thera of an antibiotic. An additional dose of the prophoperatively is not indicated in adults unless the procedure lasts for more than 4 hours, or there is bl ss o f u ve do oper prolo g prophylaxis beyond a single dose should be ed by an evidence base. I ndi reca ct m

lternative

lease refer to the full A bial Prophylaxis G s for further

on of specific a major RSA prophylaxis

rocedures. This is inmmended, particularlyn to the routine prop

ractic antibiotics if

hey will not themselves00mg IV is ad

ver MRSA. A s. Vancomycin IV 1g i d over 100 minute

ophylaxis is given as gle dose. Althouhere has been arocedures, the s

repeat doses for 2

ecommended in all but t ost exceptional circumthere is infection at thent perative site, it is

peutic coursehylactic dose into

ylactic agent intra-operatively or post-

ood lop to 15mL/kg. Post-operati

f 1500mL during surgery or haemodilution ooses of antibiotic for prophylaxis should not

therwise be given for any

f patien

ation. Any decision to explicit and support

cation

n

ts have contra-intibiotics, please conta

s to any of theicrobiology.

ommended

Procedure First line AUpper GI – Oesophageal, Gastric, Duodenal

Gentamicin 120mg IV

Uncomplicated Small bowel Appendicectomy Colo-rectal

Gentamicin 120mg IV & Metronidazole 500mg IV

Perforated or Gangrenous Appenicectomy or Colo-rectal


Biliary – laparoscopic cholecystectomy

Nil, unless converted to open procedure

Biliary – Open but uncomplicated

Gentamicin IV 120mg

Biliary – Open procedure, Complicated / Infected


ERCP – Endoscopic Retrograde Cholangio-pancreatography

Gentamicin 120mg IV

Breast Flucloxacillin IV 1g Clindamycin 600mg IV



Page 22 of 26

Gynaecology – Hysterectomy

v

Gentamicin 120mg IV & & other procedures involving Metronidazole 500mg IV or aginal or uterine incision 1g PR

Caesidaz

g arean Section Cefuroxime 1.5g IV & Clindamycin 600mMetron ole IV 500mg IV

Termination of Pregnancy Metronidazole 400 mg PO genital Chlamydia i

Add treatment for f

not ruled out, e.g. Doxycycline

ENT – Head and Neck & Clarithromycin 500mg IV & Otological Procedures Metronidazole 500mg IV Hernia repair with mesh (Open Amoxicillin 1g IV, or laparoscopic) in IV 120mg IV,

zole IV 500mg

Clindamycin 600 mg 0 Gentamic

MetronidaIV & Gentamicin 12mg IV

Urology – see also ‘Prostate’ -

negative ntamicin IV

below Choose cover from preoperative culture result

If resultsthen ge120mg

Prostate Resectiorethral) TURP

in 120mg IV n (Transu

Gentamic

Prostate Biopsy ( al) 50mg oral & 400 mg oral

Transrect Ciprofloxacin 7Metronidazole

Flucloxacillin 1g IV& g IV

planin IV Gentamicin 120m

Teico400mg

Add Metronidazole if diabeticamputation

or gangrene or

Vascular – arterial surgery in abdomen, pelvis or legs

iotic is sometimes also irafts

Antib ncorporated into vascular gTeicoplanin 400 mg IV & Gentamicin120mg IV Orthopaed

Arthroplasty, fractures

ics – clean Internal fixation of Antibiotic e.g. Gentamicin may also be incorporated

into cement, etc., if used Orthopaedics – contaminated wound, complex open fractures with extensive tissue damage

e 500mg IV or

Teicoplanin 400 mg IV &Gentamicin120mg IV &

Metronidazol1g PR

Lower limb amputation or after major trauma

yl penicillin 600mg IV QDS/ Amoxicillin 500mg PO TDS for 5 days

V Benz Metronidazole I400-500mg TDS for 5 days

Closed clean orthopaedic procedures without prosthesis

No prophylaxis recommended

Urinary Catheter ge –only s at exceptional risk

– e.g. with prosthetic implants

se cover from pre-edure culture result if

available

tive then Chanfor patient

Chooproc

If negaGentamicin 120mg IV



Page 23 of 26

icrobia guidelines with renal impair e (Doses taken from book, 3rd edition 2009, UK Renal Pharmacy Group, the Electronic

es Co dium www.emc.

29. Antim l dosing in adults ment and failur

The Renal HandMedicin mpen medicines.org.uk Sum

maries of P racteristics)

CAPD = Continuous ambulatory peritoneal dialysis HD = Intermittent HaN/A = Preparation no e or not used ard Dose for patients on r HD as per pa earanceotherwise stated.

ulat 40 – age in ye r

roduct Cha

emodialysis

t availabl routinely within Health Bo

CAPD o tients with a Creatinine Cl (CrCl) <10ml/min unless

CrCl may be calc ed by: (1 ars) x body weight (kg) (x1.25 fo men) = mL/min Serum e)

patient please contact your ward pharmacist for advice.

If patient is a dialysis

creatinine (micromoles per litr

Antibiotic

CrCl (mL per minute)

Oral Dose Intravenous Dose

> 50 200mg – 400mg 5 x /day2 tds3 5mg/kg 25 – 50 200mg – 400mg 5 x /day2 5mg/kg bd 10 – 25 g 3 – 4x /day 200m 5mg/kg od

Aciclovir

Treatment of Herpes Simplex < 10 200mg bd 2.5mg/kg od

> 50 800mg 5 x /day 5-10mg/kg tds3 25 – 50 800mg 5 x /day 5-10mg/kg bd3 10 – 25 800mg bd - tds

/kg 5-10mg/kg od3

(some units use 3.5-7mgod)

Aciclovir Treatment of Varicella Zoster 1

< 10 400mg – 800mg bd 2.5-5mg/kg od3

> 20

N/A 2.4g – 14.4g daily in 4 – 6 divided doses.

10 – 20 g N/A 600mg – 2.4g qds, dependinon severity of infection

Benzylpenicillin Note: Higher

ay) should be reserved for the treatment of meningitis and severe cellulitis

< 10 N/A ding

doses (>7.2g/d

600mg – 1.2g qds, depenon severity of infection

> 20 250mg qds or 500mg bd/tds Recurrent UTI prophylaxis: 125mg at night

N/A

10 – 20 g bd/tds 500m N/A

Cefalexin

< 10 250mg – 500mg bd/tds N/A

> 10 N/A Mild infection: 1g bd Moderate infection: 1g tds Severe infection: 2g qds Life-threatening infection: up to 12g daily in 3 – 4 divided doses.

Cefotaxime

< 10 N/A 1g bd / tds

>10 N/A 1g od; 2 – 4g daily in severe infections

Ceftriaxone

<10 N/A Dose as in normal renal function, maximum 2g daily

>50 N/A 750mg – 1.5g tds 20 – 50 N/A 750mg – 1.5g tds 10 – 20 N/A 750mg – 1.5g bd / tds

Cefuroxime

<10 N/A 750mg – 1.5g od/bd

>20 250mg – 750mg bd bd 100mg – 400mg 10 – 20 ormal dose normal dose 50% - 100% of n 50% – 100% of <10 50% of normal dose 50% of normal dose

Ciprofloxacin

D CAPD /H 250mg bd Up to 500mg bd in CAPD peritonitis

200mg bd

>30 250mg – 500mg bd 500mg bd Clarithromycin <30 250mg – 500mg bd 250mg – 500mg bd



Page 24 of 26

Antibiotic

CrCl (mL per minute)


>30 375mg – 625mg tds s

1.2g tds. Up to qds in severe infection

10 – 30 Dosefuncti

as in normal renal on

1.2g bd

Co-amoxiclav

as in normal renal on 2g bd

<10 Dosefuncti

1.2g stat followed by either 600mg tds or 1.

>30 960mg od for SBP prophylaxis 15 – 30 ylaxis 480mg od for SBP proph

Co-trimoxazole (N.B. Higher doses used for Pneumocystis)

is <15 480mg od for SBP prophylax

>50 N/A 500mg tds 30 – 50 N/A 250mg tds

Doripenem

<30 250mg bd N/A

>30 1g od N/A 10 – 30 Use 50% – 100 % of dose N/A

Ertapenem

<10 N/A Use 50% of dose or 1g three times per week

>10 250mg – 500mg qds or g – 1g bd

rate infection, /day. 500m

Mild to mode25mg/kgSevere infection or immunocompromised, 50mg/kg/day (maximum 4g/day for adults)

Erythromycin

– 75% of normal dose, maximum 2g daily

<10 50% 50% – 75% of normal dose, maximum 2g/day

>10 250mg – 1g qds 250mg – 2g qds. Endocarditis: Maximum 2g every 4 hours (if weight >85kg) Osteomyelitis: 8g/day in divided doses

Flucloxacillin

<10 Dose as in normal renal se is 4g

s in normal renal ose is 4g

daily function. Maximum dodaily

Dose afunction. Maximum d

>70 500mg/500mg – 1g/1g tds / N/A qds (Max 4g/4g per day)

31 – 70 tds – qds N/A 500mg/500mg 21 – 30 N/A 500mg/500mg bd – tds <20 500mg

d, N/A 250mg/250mg – 500mg/

bd or 3.5mg/3.5mg per kg bwhichever is lower

Imipenem / cilastatin

CAPD/HD N/A 250mg/250mg – 500mg/500mg bd or 3.5mg/3.5mg per kg bd, whichever is lower

>70 g/kg od. MN/A 5m onitor evels. l 30 – 70 -5mg/kg od . N/A 3 . Monitor levels 10 – 30 /kg od. MN/A 2-3mg onitor levels. 5 – 10 /kg every 48 – 72 hours

rding to levels. N/A 2mg

accoCAPD N/A 2mg/kg every 48 – 72 hours

according to levels.

Gentamicin

2mg/kg every 48 – 72 hours levels. Dose

HD N/A according toafter dialysis.

>50 500mg od/bd 500mg od/bd 20 – 50 Initial dose 250mg – 500mg Initial dose 2

then reduce dose by 50% then reduce dose by 50%50mg – 500mg

10 – 20 Initial dose 250mg – 500mg In

then 125mg 12 – 24 hourly itial dose 250mg – 500mg

then 125mg 12 – 24 hourly

Levofloxacin

<10 Initial dose 250mg – 500mg then 125mg 24 – 48 hourly

Initial dose 250mg – 500mg then 125mg 24 – 48 hourly



Page 25 of 26

Antibiotic

Cr Cl (mL per minute)


>50 N/A 500mg – 1g tds, up to 2g tds in meningitis / cystic fibrosis / endocarditis

20 – 50 N/A 500mg – 2g bd 10 N/A – 20 500mg – 1g bd or 500mg tds

Meropenem

<1 N/A 500mg – 1g od 0

>50 50mg – 100mg qds (or once N/A nightly for prophylaxis)

20 – 50 50mg – 100mg qds (or once N/A nightly for prophylaxis) Use with caution

Nitrofurantoin

<20 and CAPD/HD Contra-indicated: drug ineffective due to reaching inadequate urine conc. Toxic

N/A

plasma co centrations can noccur with adverse effects.

>20 N/A 4.5g tds (qds for neutropenic sepsis)

10 – 20 N/A 4.5g bd/tds

Piperacilazobac

N/A

lin / T tam

<10 4.5g bd

>10 600mg – 1200s divided doses mg daily in 600mg – 1200mg daily in

divided doseRifampicin

<10 50-100% of normal dose 50-100% of normal dose

>20 N/A Initially 400mg 12 hourly for 3 doses then subsequently 400mg od

10 – 20 N/A Give normal loading dose then 200mg – 400mg every 24 – 48 hours

Te

<10 Giv in200 evhou

icoplanin

N/A e normal loadmg – 400mg rs

g dose then ery 48 – 72

>50 mdepending on y Clostridium d

b evels. 125mg – 500 g qds severitficile

of 1g

if

d. Take l

20 – 50 Dose as in no al renal function

500mg – 1g od/bd. ake v s.

rm Tle el

10 – 20 Dose as in no al renalfunction

0 g – 1g every 24 – 48 ours based on levels.

rm 50h

m

Vancomycin

<10 Dose as in no al renalfunction

1g every 48 – 96 hours based on levels.

rm 500mg –

rD

ug that d not usually require dose a justments include: s o d

Amoxicillin Doxycycline

Moxifloxacin

Tigecycline

4

Azithromycin Linezolid4 Penicillin V Trimethoprim

Clindamycin Metronidazole Sodium fusidate 4

For drugs not listed please contact your Ward Pharm 1 Where a age range is given the higher d or severely immuno ients. These patie higher doses than those quoted.2 For prop plex reduce d es daily.

Treatme Encephalitis – e (10mg/kg) quoted. Contact ward pharmacist if CrCl < 10mL/min or patient is on dialysis.

acist.

ed fdos ose should be reservay require muchcompromised pat

nts m

hylaxis of Herpes Simnt of Herpes Simplex

osing frequency to four timuse IV dose at higher rang3

4


Status: Issue 3 Issue date: 4 March 2013

30. Guidelines for ONCE daily gentamicin administration in adults

of

g/kg od)

erCre

e ic

ven or

administration

Tbtaken for level*

in

g/L Signature

Exclusion criteria for once daily dosing is severe renal impairment, pregnancy and post-partum women, endocarditis, dialysis, ascites, cystic fibrosis and major burns (more than 20% of body). Ward:_______________________________ Diagnosis:___________________________ Actual Body Weight:___________________ Height:______________________________

Affix patient’s addressograph

here

REMEMBER TO WRITE GENTAMICIN ON PATIENT’S REGULAR DRUG CHART WITH ‘SEE GENTAMICIN CHART’ ALONG SIDE.

Dose: In patients with normal renal function give 5mg/kg Ideal Body Weight (maximum

560mg) to the nearest 40mg increment. (Neutropenic policy exempt: states 6m To calculate a patient’s ideal body weight: If patient’s actual body weight is 30% more than IBW: Males: IBW = 50kg + 0.9kg for every cm over 152cm Females: IBW = 45.5kg + 0.9kg for every cm over 152cm

Adjusted body weight = IBW + 0.4(Actual body weight – IBW)

For patients with renal impairment contact microbiology or medicines information.

Administration: The daily dose should be diluted in 100mL sodium chloride 0.9% or glucose 5% and administered over 60 minutes. Do not wait for level results before administering the next dose if patient has normal renal function. Date S um

atinine Timgentamgi

in Nurse’s signature f

ime lood

Gentamiclevel (m ).

When next dose due.

Approved by: Clinical Standards & Policy Group Review by date: 4 March 2016 Page 26 of 26

1 2 3 4 5 6 7

gentamicinue

in 24 ess

d ctor hasotherwise

ecified

Next

dose d

unlo

sp

*Levels: All level ould be taken prio next dose (pre-dose lev ls). Peak se levels are not re ired First lev ould be taken prio o the third dose unless t atient i cutely unwell wher he level may need to be taken oner. Sample eatinine should be c ecked every other day an crease equency of levels if nal functi worsens. If patien s renally stable and e dose was not altered aft r the 3rd dose then a say every -7 days.

Adjust dose depending on gentamicin evel as shown in table below

s sh r to e do quel sh r t he p s a e t

socrt i

h th

d ine

fr re 5

on s

l .

Pre-dose (mg/L) (Trough level)

Ideal range <1 Level too high Reduce frequency



Page 27 of 26

UGuidelines for MULTIPLE daily gentamicin administration in adults

Exclusion criteria for once daily dosing is severe renal impairment, pregnancy and post-partum women, endocarditis, dialysis, ascites, cystic fibrosis and major burns (more than (20% of body). Ward:_______________________________ Diagnosis:___________________________ Actual Body Weight:___________________ Height:______________________________

REMEMBER TO WRITE GENTAMICIN ON PATIENT’S REGULAR DRUG CHART WITH ‘SEE GENTAMICIN CHART’ ALONG SIDE.

Dose: 3 to 5mg/kg Ideal Body Weight per day in divided doses, every 8 or 12 hours. Usually 120mg loading dose, then 80mg or 120mg every 8 to 12 hours. Dose to the nearest 40mg increment. To calculate a patient’s ideal body weight: If patient’s actual body weight is 30% more than IBW: Males: IBW = 50kg + 0.9kg for every cm over 152cm Females: IBW = 45.5kg + 0.9kg for every cm over 152cm

Adjusted body weight = IBW + 0.4(Actual body weight – IBW)

For patients with renal impairment contact microbiology or medicines information.

Administration: The daily dose should be diluted with 50-100mL sodium chloride 0.9% or glucose 5% and administered over 20-30 minutes. Do not wait for level results before administering the next dose if patient has normal renal function.

Time level taken

Gentamicin levels mg/L

Day Date & time dose to be given (00:00hrs)

Actual time given (00:00hrs)

Nurse’s signature of administration

Pre Post Pre Post

Reviewed by doctor/ pharmacist

1

2

3

4

5

6

Levels will need to be taken more regularly in renal impairment or deteriorating patients. If patient is renally stable and no adjustments were required after the first levels (at the third dose), assays should be taken every 3-5 days. Adjust dose depending on gentamicin level as shown in table below.

Pre-dose (mg/L) Prior to next dose


Ideal range (other than Streptococcal or Staphylococcal endocarditis)

<2 5-10

Streptococcal or Staphylococcal endocarditis <1 3-5 Level too high Reduce frequency Reduce dose Level too low Increase dose

Affix patient’s addressograph

here

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