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Gloucestershire Care Services Inpatient Antibiotic Guidelines For Review June 2017

Antibiotic Guidelines for Inpatients

These guidelines are intended solely for use by healthcare professionals employed/engaged by Gloucestershire Care Services NHS Trust to aid the treatment of inpatients currently within the Trust's care. They are developed to support antibiotic stewardship.

The guidelines reflect local sensitivities and infection control issues and, unless otherwise stated, are intended for the treatment of immuno-competent adult patients.

The guidelines are intended for initial treatment and may be modified when microbiology results are available.

For clinical advice or if the patient fails to respond, discuss with senior member of the clinical team and if necessary, the Consultant Microbiologist.

Mon-Fri 09.00-17.00 ext. 4430 CGH and 5050 GRH

For urgent advice out of hours, contact the "On-Call Consultant Microbiologist" via switchboard.

The most up to date version will be available on the organisation’s intranet. If using a printed version you must ensure it reflects the most up to date information

Authors Dr James Stone, Consultant Microbiologist

Laura Bucknell, Head of Medicines Management Approved by: GCS NHS Trust Medicines Management Committee Gloucestershire Antimicrobial Stewardship Committee

For Review June 2017


Contents page

Principles for use of guidelines 3

Penicillin Allergy 4-5

IV to oral switch 6

Hyposplenism 7

Therapeutic drug monitoring (TDM) 8-14

Gentamicin 8

Tobramycin 10

Amikacin 11

Teicoplanin 12

Vancomycin 13

Upper Respiratory Tract Infections 15

Influenza 15

Sore throat/pharyngitis/tonsillitis 15

Lower Respiratory Tract Infections 16-22

Acute cough/bronchitis 16

Infective exacerbation COPD 17

Community acquired pneumonia 18

Influenza related pneumonia 20

Aspiration pneumonia 21

Hospital acquired pneumonia 22

Urinary Tract Infections 23-24

Meningitis 25

Viral meningo Encephalitis 25

Skin and Soft Tissue Infections 26-30

Impetigo, shingles, chickenpox, cold sores 26

Cellulitis 27

Facial cellulitis, periorbital cellulitis 28

Leg ulcers and diabetic ulcers 29

Osteomyelitis, sepsis arthritis 30

Conjunctivitis 31

Gastrointestinal Infections 32-36

Intra – abdominal sepsis, peritonitis, diverticulitis 32

Biliary tree 33

Spontaneous bacterial peritonitis 34

C Difficile Infection 35

Genital Tract Infections 37-38

Pelvic inflammatory disease 37

Epididymo-orchitis 37

Prostatitis 37

MRSA Treatment 38

MRSA Decolonisation 38


PRINCIPLES FOR USE OF GUIDELINES

These guidelines are based on the best evidence at the time of publication

PRESCRIBE ANTIBIOTICS ONLY WHEN THERE IS LIKELY TO BE CLEAR CLINICAL BENEFIT

A dose and duration for treatment of adults is included in the guideline but may need modification for age, weight and renal function.

Avoid broad spectrum antibiotics when narrow spectrum antibiotics remain effective, as they increase the risk of C.Diff, MRSA and resistant UTIs

Topical antibiotics are only appropriate for MRSA decolonisation or localised impetigo In-patients

The Sepsis Six are 6 tasks which when delivered to patients within one hour of recognition of sepsis, can half the risk of death for patients (Surviving Sepsis Campaign) 1. 100% Oxygen 2. IV fluid bolus 3. Blood cultures 4. IV antibiotics 5. Lactate & bloods 6. Monitor urine output

Specimens for Microbiology, Culture & Sensitivity (MC&S) should always be taken before starting antibiotics. (Blood cultures – 2 sets from 2 sites)

Check previous microbiology results before prescribing and check new results daily and rationalise therapy accordingly

Individual patient factors to consider in all cases: · Previous antibiotic history · Previous infection with multi-resistant organisms (e.g. MRSA, ESBLs) · Allergies, Renal & Hepatic function · Pregnancy or breastfeeding · Immuno-compromised · Availability and absorption by oral route

INDICATION AND REVIEW/STOP BOXES MUST BE COMPLETED ON THE DRUG CHART

Intravenous therapy (IV) to be used only for severe conditions and if oral route unavailable/unsuitable. Review IV therapy every 48 hours and oral antibiotics within 5 days.

For patients prescribed Gentamicin: dose adjustment for Creatinine Clearance and Therapeutic Drug Monitoring (TDM) is required (pg 8)


PENICILLIN ALLERGY The label of penicillin allergy is often incorrect. It will result in many life-saving antibiotics being ruled-out as options available for therapy. When recording a 'penicillin-allergy' on the drug chart or in the patient medical records try wherever possible to clarify the nature of the allergy in as much detail as possible. Penicillin associated with diarrhoea for example is NOT allergy. This may necessitate discussion with family and friends, GPs or other healthcare professional who have been involved in previous episodes of medical treatment.

Useful information:

True IgE mediated Penicillin allergy is very rare (only 1 in 100 so labelled have genuine allergy)

Where true allergy is suspected and alternative antibiotics are severely limited consider referral to immunology for evaluation after discussion with microbiology.

Individuals with Severe Penicillin Allergy (see above) MUST NOT receive a penicillin, cephalosporin or another beta-lactam antibiotic. Individuals with Non-Severe Penicillin Allergy (see above) MUST NOT receive a penicillin but cephalosporins, carbepenems and other beta-lactams can be used for these patients with caution as the risk of cross sensitivity is low.

Penicillin Antibiotics

Amoxicillin (Amoxil®)

Benzylpenicillin (Crystapen®)

Co-amoxiclav (Amoxicillin/Clavulanic acid = Augmentin®)

Flucloxacillin (Floxapen®)

Severe Penicillin Allergy (Type 1 immediate IgE mediated reactions)

Severe life-threatening adverse reactions due to immediate hypersensitivity are very uncommon. Timing of onset: Normally within 1 hour of administration but can be up to 12 hours Characteristic clinical signs:

Anaphylaxis

Angioedema

Urticarial rash/pruritus

Wheezing/stridor

Non-Severe Penicillin Allergy Types II-IV and idiosyncratic reactions)

Timing of onset: more than 24 hours from administration of antibiotic

Characteristic clinical signs:

Maculopapular/morbilliform rash

Serum sickness (fever, rash, arthralgia, glomerulonephritis)


Co-fluampicil (Flucloxacillin/Ampicillin = Magnapen®)

Piperacillin/Tazobactam (Tazocin®)

Phenoxymethylpenicillin (Penicillin V)

Temocillin (Negaban®)

Ticarcillin/Clavulanic acid (Timentin®)

Other beta-lactam antibiotics

Cephalosporins (e.g. Cefuroxime, Ceftriaxone, Cefradine)

Ertapenem (Ivanz®)

Imipenem/Cilastatin (Primaxin®)

Meropenem (Meronem®)

Aztreonam (Azactam®) - may be used with caution in severe penicillin allergy: discuss with microbiology

Documentation and clarification of penicillin allergy

Ask your patient about their allergy - which drug & what happened?

Document the allergy - on drug chart and in medical notes


IV to oral switch Guideline

N.B. Excludes severely immunocompromised patients such as chemotherapy-related neutropenia and/or bone marrow transplant.

The majority of patients with a severe infection who are adequately absorbing oral medication and initially require IV therapy can be safely switched to oral therapy within 48 hours

For considerations for early switch to oral therapy see “COMS”.

Patients should generally have all of the ‘COMS’ criteria

Review at 24-48 hours after starting IVs and then at least every 48 hours

C Clinical improvement observed

O Oral route is not compromised by vomiting, malabsorptive disorder, nil by mouth, swallowing problems, un-conscious, severe diarrhoea. Suitable oral antibiotic option available. NB: if NG/PEG feeding consult pharmacy

M

Markers showing trend towards normal:

Apyrexial for the last 24hrs

Temp greater than 36°C and less than 38°C AND no more than one of the following: - CRP greater than 100mg/L - Heart rate greater than 90/min - Respiratory rate greater than 20/min - BP unstable - WCC less than 4x10

9/L or greater than 12x10

9/L. White cell count should show a trend

towards normal; absence of such should not impede oral switch if all other criteria are met and not neutropenic

S No Specific indication/deep seated infection requiring prolonged IV therapy where oral switch is inappropriate including: Endocarditis, Meningitis, Bone/Joint infections.


GUIDELINES FOR THE PROTECTION OF PATIENTS WITH AN ABSENT OR DYSFUNCTIONAL SPLEEN (HYPOSPLENISM).

Asplenic patients are at a greater risk of developing fulminant, life-threatening sepsis and so must be appropriately vaccinated and receive antibiotic prophylaxis. The main causative organisms are:

Streptococus pneumoniae

Haemophilus influenzae

Neisseria meningitidis. Click here for splenectomy guidelines or view the documents on the clinical policy page of the intranet

https://nww.gloscareservices.nhs.uk/publications/Policies/Spleen%20-%20Guidelines%20for%20the%20protection%20of%20patients%20with%20an%20absent%20or%20dysfunctional%20spleen%20CP02%20(rev.%20Apr%202015).pdf


THERAPEUTIC DRUG MONITORING (TDM)

TDM is required for all patients on aminoglycoside and glycopeptide antibiotics: Gentamicin, tobramycin, amikacin and vancomycin. Teicoplanin monitoring is required weekly Levels are performed on clotted samples (gold caps). For all samples information on start date, time of sampling, and dosing regimen MUST be included in order to allow interpretation of results. Currently gentamicin, tobramycin and vancomycin levels should be sent to Clinical Chemistry (green request forms). All other antibiotic levels should be sent to Microbiology (blue request forms). This may change: check GHNHSFT Pathology website if unsure.

1. GENTAMICIN

Gentamicin – principles of use and monitoring

Aminoglycoside antibiotic – same group as Streptomycin, tobramycin, netilmicin, amikacin, neomycin, kanamycin

Broad-spectrum vs Gram negative and Gram positive aerobic bacteria

Most important activity is against aerobic Gram negative bacilli i.e. coliforms and pseudomonas

Not active against strict anaerobes

Synergistic activity vs Streptococci (endocarditis)

Only active when used topically or given parenterally

Main uses – UTI, intra-abdominal sepsis (combined with e.g. amoxicillin and metronidazole) and “Gram-negative sepsis”

Narrow therapeutic index – dose needs to be carefully calculated and levels monitored to ensure therapeutic and non-toxic levels achieved

All patients receiving gentamicin must have levels monitored, primarily to avoid renal toxicity

Renal function should also be regularly monitored

For most patients requiring a gentamicin course a once daily dosing regime can be used

Gentamicin levels can be taken at any time of day but the collection time should be convenient for the patient and for the testing laboratory – sampling and testing between 12 midnight and 6 am should be avoided –see "when to test"

Most gentamicin levels are a planned non-urgent investigation

Gentamicin levels are performed both at CGH and GRH Chemical Pathology – please send requests using green Chemistry request forms to avoid delays in sample receipt and analysis

For requests out of hours please contact the on call biomedical scientist in Chemical Pathology to inform them that a sample is being sent

Gentamicin and Renal Function

Renal impairment – use gentamicin with caution Creatinine clearance calculated using Cockcroft-Gault equation rather than eGFR All patients on gentamicin need levels and U+Es monitoring (U+Es every 48 hours) Sepsis can lead to transient renal impairment Acute renal impairment in sepsis – give “full” gentamicin dose initially to avoid under

treatment of more severe sepsis Dosing ONCE DAILY GENTAMICIN:

Adult dose 5mg/kg. Over 65yrs 3mg/kg (or lower in renal impairment)

Always use ideal body weight (IBW) rather than actual body weight (ABW) as Gentamicin poorly distributed in body fat.

For obese patients (BMI greater than 30 or 120% of IBW) calculate dose using the weight obtained from the following formula

Obese patient dosing weight: IBW + 0.4 (ABW-IBW) For males IBW = 50kg +(2.3kg x height in inches over 5 feet)

For females IBW = 45.5 kg + (2.3 x height in inches over 5 feet)


Administration Once daily as an intravenous infusion in 100mL dextrose 5% or sodium chloride 0.9% over 60 minutes. Evening administration is recommended Caution in renal impairment. (GFR less than 30mL/min) Monitoring

For a once daily dosing regime samples should be taken 12 to 18 hours after the dose.

If the levels are within the recommended range with normal renal function then the levels should be repeated twice weekly

Blood sample forms must include:

Date and time of drug administration

Date and time of blood sampling

Dose per kg administered (e.g. 5mg/kg)

Dosing regime (e.g. once daily)

Target serum Gentamicin concentration for once daily dosing in adults: 12 hours post dose = less than 2mg/L 18 hours post dose = less than 1mg/L

If Serum gentamicin concentration is less than 2mg/L (12hrs post infusion) or less than1mg/L (18hrs post infusion) then the present dose is correct for the patient’s existing renal function. This shows no accumulation therefore continue with the same daily dose If Serum gentamicin concentration is greater than 2mg/L (12hrs post infusion) or greater than 1mg/L (18hrs post infusion) then the present dose is too high for the patient’s existing renal function. Dose reduction to a new dose will be required as per this equation New Dose = Previous dose x Target serum level Actual serum level (round to the nearest 40mg)

Serum gentamicin levels should be rechecked 12 to 18 hours after the new dose. If gentamicin levels are within the recommended range with normal renal function then

monitor levels and U&Es twice weekly. Exclusions: Once daily Gentamicin is inappropriate and should not be used in: endocarditis, pregnancy, major burns, ascites, osteomyelitis or myeloma.


Calculating the initial gentamicin dose in renal impairment Dose adjustment for impaired renal function Cockroft-Gault equation for estimating creatinine clearance: Creatinine Clearance (GFR) = (140 - Age) x Weight (Kg) x F Serum Creatinine (micromol/litre) Where F = 1.23 (For Men)

1.04 (For Women) Dose adjustment recommendations: Cr Cl (ml/min) Dose 30-70 3-5mg/kg once-daily 10-30 2-3mg/kg once-daily 5-10 2mg/kg every 48 to 72 hours according to levels BD OR TDS GENTAMICIN: These regimens are only appropriate for specific conditions such as infective endocarditis. Dosing and reference ranges depend on the condition. Specialist advice from a Microbiologist should be sought.

2. TOBRAMYCIN:

Tobramycin should only be prescribed on specialist Microbiology or Respiratory Physician advice. All patients receiving tobramycin must have levels monitored, primarily to avoid renal toxicity

Renal function should also be regularly monitored

For most patients requiring a tobramycin course a once daily dosing regime can be used

Tobramycin levels can be taken at any time of day but the collection time should be convenient for the patient and for the testing laboratory – sampling and testing between 12 midnight and 6 am should be avoided –see "when to test"

Most tobramycin levels are a planned non-urgent investigation

Tobramycin levels are performed both at CGH and GRH Chemical Pathology – please send requests using green Chemistry request forms to avoid delays in sample receipt and analysis


Once daily tobramycin should not be used in pregnancy, major burns and ascites. Dosing Patients without cystic fibrosis Give 3-5mg/kg (3mg in patients over 65 years of age) once daily as an intravenous infusion in 100mls of dextrose 5% or sodium chloride 0.9% over 60 minutes. Round dose up or down to the nearest 40mg When to give the dose

The first dose may be given at any time of day (i.e. as soon as is needed). Subsequent doses should be moved to a time that is convenient for both the patient and the chemical pathology department.

When to test

For a once daily dosing regime samples should be taken 12 to 18 hours after the dose. If the levels are within the recommended range with normal renal function then the levels should be repeated twice weekly

Use ideal body weight (IBW) rather than actual body weight (ABW) because tobramycin distributes poorly in fat. For obese patients (BMI greater than 30 or greater than 120% of ideal body weight|), it is recommended that the dose is calculated using the patient’s obese dosing body weight Obese dosing body weight (ODBW) = IBW + 0.4 (ABW-IBW)


For patients on bd or tds tobramycin regimes paired pre and 1 hour post-dose levels should be taken – the first levels should be taken when the patient has been on tobramycin for 48 hours. Repeat levels should be taken every 5-7 days if the first levels were satisfactory and the renal function is satisfactory and stable. If the first levels were unsatisfactory and the regime was altered, the levels should be repeated 48 hours after the regime change

If the renal function is abnormal or changing the levels should be monitored more frequently (every 2 days)

Results If there is any doubt regarding interpretation, or a dose change needs to be discussed, then contact the Consultant Microbiologist Normal levels Target levels for once daily dosing in adults: 12 hours post-dose = less than 2 mg/L 18 hours post-dose = less than 1 mg/L If serum tobramycin concentration is: Less than 2mg/l (12 hours post infusion) or less than 1mg/l (18 hours post infusion) then the present dose is correct for the patient’s existing renal function. This shows no accumulation; therefore continue with the same daily dose Greater than 2mg/l (12 hours post infusion) or greater than 1mg/l (18 hours post infusion) then the present dose is too high for the patient’s existing renal function. Dose reduction to a new dose will be required as per the following equation: New dose = previous daily dose x target serum value Actual serum level Serum tobramycin levels should be rechecked 12-18 hours after the new dose

3. AMIKACIN:

Amikacin is a restricted antibiotic and should only be prescribed on Microbiology advice.

Amikacin assays are sent for processing offsite. Levels should reach the laboratory for 2pm Mon-Fri and results are usually available for the following lunchtime. Results from Amikacin assays taken on Saturdays, Sundays or Bank Holidays are usually available on the following Tuesday lunchtime

Once daily amikacin is not suitable for use in pregnancy or post-partum, enterococcal endocarditis, ascites or major burns

Dosing 15mg/kg once daily (use actual body weight unless obese), up to a maximum dose of 1.5g/day. The daily dose should be given over 60 minutes in 100ml sodium chloride 0.9% or glucose 5% A lifetime dose of 15g should not be exceeded. In patients with renal impairment, determine the dose and dosing interval using the following guide: CrCl greater than 90ml/min = 15mg/kg every 24 hours

Dosing in obesity If patients are greater than 120% of their IBW, dosage must be calculated using the Obese Dosing Weight (ODW) ODW = IBW + 0.4 (actual body weight – IBW) NB: IBW (kg) = 50+ (2.3 x inches over 5 feet) in males 45.5 + (2.3 x inches over 5 feet) in females


CrCl 70-89 ml/min = 12mg/kg every 24 hours CrCl 50-69 ml/min = 7.5mg/kg every 24 hours CrCl 30-49ml/min = 4mg/kg every 24 hours CrCl 20-29 ml/min =7.5mg/kg every 48 hours CrCl 10-19 ml/min = 4mg/kg every 48 hours CrCl less than 10ml/min = 3mg/kg every 48 hours Monitoring Trough levels are taken immediately prior to the 2

nd dose

If trough level less than 5 mg/l, prescribe next dose if required. Thereafter, monitor amikacin level and U&Es twice weekly. If serum creatinine rises by more than 45 micromoles/l stop amikacin and discuss with Microbiology.

If trough level greater than 5 mg/l, omit next dose and take another level 12hrs later. Do not administer more amikacin until level falls below 5 mg/l. Contact Microbiology for advice on revising dosage regime.

If greater than 48hrs treatment is anticipated, baseline audiometry should be measured and kept under review. Additionally, monitor the cumulative dose (maximum is 15 grams).

4. TEICOPLANIN

Doses based on actual body weight and indication.

Loading doses are given every 12 hours for 4 - 5 doses depending on indication.

Maintenance doses are given ONCE DAILY starting 24 hours after the last loading dose.

Take a pre-dose level on the 5th day and weekly thereafter.

Dose adjustment needed in renal impairment (CrCl less than or equal to 30ml/min)- see below

Indication Respiratory, Cellulitis, Neutropenic Sepsis and Unknown Source Infections

Bone and Joint Infections Infective Endocarditis

Dose (based on actual body weight)

<50kg 400mg 600mg 600mg

50-100kg 600mg 800mg 800mg

>100kg 800mg 1200mg 1200mg

Loading

Frequency 12 hourly 12 hourly 12 hourly

Duration 4 doses 4 doses 5 doses

Maintenance

Frequency Once a day Once a day Once a day

Starting 24 hours after loading 24 hours after loading 24 hours after loading

Levels (trough - prior to dose)

When Day 5 Day 5 Day 5

Target range 15-60mg/L 20-60mg/L 30-60mg/L

Repeat Weekly unless advised otherwise

Weekly unless advised otherwise


Monitoring Teicoplanin levels are sent to a regional centre. They are non-urgent investigations and efforts should be made to avoid routine testing (and sampling) at weekends. The initial pre-dose assay sample should be collected just before the dose given on the 5th day. If this falls on a Sunday, the sample


can be taken as planned and should be sent to Pathology Specimen Reception on the Sunday for dispatch for testing on the next working day If a patient is on a prolonged course of teicoplanin (greater than 2 weeks) and the initial levels are satisfactory, repeat levels should be monitored weekly. Otherwise, the Consultant Microbiologist will advise on repeat sampling, if indicated

Result interpretation

Results are reported with a standard interpretative comment that gives the recommended target (normal) levels

If there is any doubt regarding interpretation, contact the Consultant Microbiologist

Dosing in renal impairment

Dosing recommendations are based on creatinine clearance calculated using the Cockcroft-Gault equation.

Dose adjustment may not be appropriate in ACUTE renal impairment secondary to SEPSIS. In this case it is important to treat the infection aggressively for the first 24hrs and re-check renal function before reducing the dose accordingly.

(In 'acute on chronic' renal impairment the initial dose should correspond to the previous level of chronic renal impairment).

CrCl (ml/min) Dose

Greater than 30 Normal loading and maintenance dosing

Less than or equal to 30

Normal loading and maintenance dosing up to and including day 4. The original dose should then be continued every 72 hours.

5. VANCOMYCIN:

Vancomycin levels can be taken at any time of day but the collection time should be convenient for the patient and for the testing laboratory – sampling and testing between 12 midnight and 6 am should be avoided – see "when to test"

Most vancomycin levels are a planned non-urgent investigation

Vancomycin levels are performed at Chemical Pathology on the GRH site – please send requests using a Chemical Pathology request form to avoid delays in sample receipt and analysis


When to test

Indication

Respiratory, Cellulitis,

Neutropenic Sepsis and

Unknown Source Infections

Bone and Joint Infections Infective Endocarditis

Levels (trough - prior to dose)

When Day 5 Day 5 Day 5

Target Range 15-60mg/L 20-60mg/L 30-60mg/L

Repeat Weekly unless advised otherwise




Monitoring is required for patients receiving IV vancomycin but not oral

Only pre-dose (trough) levels are required.

For adults, samples should be collected just before the 4th or 5th dose - earlier if there is renal compromise or the patient is on other nephrotoxic drugs

CrCl (ml/min) Dose

Greater than 70 1 g bd. Check pre-dose level before fourth or fifth dose

50 - 70 750 mg bd. Check pre-dose level before fourth or fifth dose

20 - 50 500 mg bd. Check pre-dose level before third dose

10 - 20 500 mg od. Check pre-dose level before second dose

Less than 10 500mg every 48 hours. Check pre-dose level before second dose

Normally levels can be monitored every 3 - 4 days if the initial level was satisfactory and renal function is stable

For routine monitoring of pre-dose levels the patient should continue receiving subsequent dose(s) of vancomycin pending getting the results of the vancomycin levels back. Doses of vancomycin should not be omitted in these circumstances.

When a patient is having a random vancomycin level checked to see if a high previous level has dropped to an acceptable level it is reasonable to withhold further doses of vancomycin until the results of the random vancomycin level are known

Circumstances when vancomycin should be withheld should be discussed with a specialist clinician.

Result Interpretation

Normal levels:

Pre-dose levels should be 10 - 15 mg/L routinely *

Post-dose levels are NOT required

* Except where advised otherwise by a Consultant Microbiologist (e.g. pre-dose levels in staphylococcal endocarditis should be 15-20 mg/L)

The Consultant Microbiologist can advise on dose adjustment for abnormal levels, and repeat sampling, if necessary.

Normally levels can be monitored every 3 - 4 days if the initial level was satisfactory and renal function is stable.


UPPER RESPIRATORY TRACT INFECTIONS:

Consider no antibiotics or delayed prescription

INFLUENZA (see Health Protection Agency (HPA) website, www.hpa.org.uk)

Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults, vaccination is not recommended. Groups of patients considered ‘at risk’ is published annually by the Department of Health. Anti-virals can lessen symptoms by a couple of days and reduce the severity and likelihood of complications. When influenza is circulating in the community the Chief Medical Officer will advise when anti-virals can be prescribed in line with NICE guidance.

SORE THROAT/PHARYNGITIS/TONSILLITIS Avoid antibiotics as 90% resolve in 7 days without antibiotics and pain is only reduced by 16 hours. If centor score 3 of 4: (lymphadenopathy, no cough, fever, tonsillar exudate) consider 2 or 3 day delayed prescription, or immediate antibiotics. Antibiotics to prevent Quinsy NNT (Number Needed to Treat): greater than 4000. Antibiotics to prevent Otitis media: NNT 200

Severity 1st

line Penicillin Allergy (see explanatory notes)

If antibiotic treatment clinically indicated

PHENOXYMETHYLPENICILLIN 500mg QDS oral, or 1g BD oral (use QDS when severe) Treatment duration : 10 days

CLARITHROMYCIN 250-500mg BD oral Treatment duration: 5 days

http://www.hpa.org.uk/


LOWER RESPIRATORY TRACT INFECTIONS Low doses of Penicillins are more likely to select out resistance. Do NOT use quinolones (Ciprofloxacin, Ofloxacin) first line due to poor activity against pneumococci. Reserve all quinolones (including Levofloxacin) for proven resistant organisms. Avoid Tetracyclines in pregnancy.

ACUTE COUGH, BRONCHITIS

· In acute bronchitis antibiotics have little benefit unless there is co-morbidity. · Symptom resolution can take 3 weeks. If antibiotic treatment is indicated

Severity 1st


Minor to moderate infection Review doses in renal impairment

AMOXICILLIN 500mg TDS oral

Treatment duration : 7 days

DOXYCYCLINE 200mg ONCE DAILY oral

Treatment duration : 7 days

Moderate to Severe Review doses in renal impairment

AMOXICILLIN 500mg TDS oral PLUS DOXYCYCLINE 200mg ONCE A DAY oral If prior treatment with either Amoxicillin or Doxycycline use: CO-AMOXICLAV 625mg TDS oral as monotherapy

(If poor clinical response DISCUSS with specialist PHYSICIAN or MICROBIOLOGIST)

Treatment duration: 7 days

DOXYCYCLINE 200mg ONCE DAILY oral as monotherapy

OR if contraindicated or prior treatment with doxycycline, use:

CLARITHROMYCIN 500mg BD oral as monotherapy

Treatment duration: 7 days

Severe consider transfer to an acute setting

CO-AMOXICLAV 1.2g TDS IV

Treatment duration: 7 - 10 days

LEVOFLOXACIN 500mg BD oral/IV (Oral route preferred. Consider reducing to 500mg od if patient clearly improving) Treatment duration: 7 - 10 days

IV to oral switch

CO-AMOXICLAV 625mg TDS oral (unless

lab results indicate otherwise)

Treatment duration: total of 7-10 days

LEVOFLOXACIN 500mg ONCE DAILY oral

Treatment duration: total of 7-10 days


INFECTIVE EXACERBATION COPD (oral)

Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume. 30% are viral, 30-50% bacterial, the rest undetermined. Some patients may need longer than 5 days treatment. Risk factors for resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in the last 3 months.

Severity 1st

line If contra-indicated


DOXYCYCLINE 200mg ONCE DAILY oral Treatment duration: 7 days If unresponsive to treatment or previously treated with amoxicillin or doxycycline discussed consider: CO-AMOXICLAV 625mg TDS oral Treatment duration: 7 days

AMOXICILLIN 500mg TDS oral Treatment duration: 7 days If also penicillin allergy: CLARITHROMYCIN 500mg BD oral Treatment duration: 7 days

If the patient has bronchiectasis consider discussion with a Microbiologist or Respiratory Physician as prior culture results need to be considered and anti-pseudomonal cover may be required.

ACUTE BRONCHITIS/INFECTIVE

EXACERBATION COPD (IV)

CONSIDER TRANSFER TO ACUTE SETTING

Severity 1st



If IV necessary: CO-AMOXICLAV 1.2g TDS IV Review IV therapy every 24 hours until switch to oral therapy is appropriate

Levofloxacin 500mg BD oral


COMMUNITY ACQUIRED PNEUMONIA

Evidence of consolidation on CXR

Clinical findings and severity rating using CURB-65 must be documented

Collect sputum and blood cultures (If raised temperature)

Atypical pneumonia serology and Pneumococcal and Legionella urinary antigen if indicated

Mycoplasma infection is relatively rare in elderly (65 years and over)

Seek risk factors for legionella and Staphylococcus aureus infection Use CURB-65 score to help guide and review

CURB-65 Severity rating score for CAP. 1 point for each below

C Mental confusion (AMT less than 8)

U Blood Urea greater than 7mmol/L

R Respiratory Rate greater than 30/min

B Low blood pressure (diastolic less than 60mmHg or systolic less than 90mmHg

65 Age greater than 65 years

Score 0: suitable for home treatment Score 1-2: assessment, consider community hospital referral/admission Sore 3-4: - urgent hospital admission

Severity 1st


Minor to moderate infection CURB-65 SCORE 0-1 (Review dose in renal impairment)

AMOXICILLIN 500mg TDS oral If atypicals suspected use: DOXYCYCLINE 200mg ONCE DAILY oral Treatment duration: 7 days

DOXYCYCLINE 200mg ONCE DAILY oral If contra-indicated or if prior treatment with doxycycline Use: CLARITHROMYCIN 500mg BD oral Treatment duration: 7 days

Moderate to Severe CURB-65 SCORE 2 (Review doses in renal impairment)

AMOXICILLIN 1g TDS oral PLUS CLARITHROMYCIN 500mg BD oral Treatment duration: 7 days

CLARITHROMYCIN 500mg BD oral as monotherapy If poor clinical response discuss with microbiologists. If recent use of clarithromycin use: LEVOFLOXACIN 500mg BD oral

Consider reducing to 500mg od if patient clearly improving Treatment duration: 7 days

Severe/life threatening CURB-65 score 3-5

FIRST DOSE THEN CONSIDER TRANSFER TO ACUTE TRUST

BENZYLPENICILLIN 2.4g QDS IV PLUS CLARITHROMYCIN 500mg BD oral/IV PLUS GENTAMICIN 5mg/kg IV stat (3mg/kg if over 65 years of age) If serum creatinine 150-300 micromol/L use GENTAMICIN 80-120mg IV stat

LEVOFLOXACIN 500mg BD oral/IV (Oral route preferred. Consider reducing to 500mg od if patient clearly improving) PLUS TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l


Gentamicin therapy to be reviewed after 24 hours. Continue only if evidence of gram –ve sepsis and discuss with Consultant Microbiologist. Check level 12-18hrs after first dose If suspected MRSA add: TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l

If laboratory evidence of pneumococci Non-severe penicillin allergy: CEFTRIAXONE 2g ONCE DAILY IV PLUS CLARITHROMYCIN 500mg BD ORAL/IV Severe penicillin allergy: TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l Plus CLARITHROMYCIN 500mg BD oral/IV

http://intranet/en/Trust-Staff/Antibiotic-Guidelines/Penicillin-Allergy/



INFLUENZA RELATED PNEUMONIA

Severity 1st



DOXYCYCLINE 200mg ONCE DAILY oral Or if prior treatment with doxycycline CO-AMOXICLAV 625mg TDS oral Treatment duration: 7 days

DOXYCYCLINE 200mg ONCE DAILY oral Or if prior treatment with doxycycline CLARITHROMYCIN 500mg BD oral Treatment duration: 7 days

Moderate to Severe Consider transfer to the acute settings Review doses in renal impairment

CO-AMOXICLAV 1.2g TDS IV (or Co-amoxiclav 625mg TDS oral, depending upon severity assessment) PLUS CLARITHROMYCIN 500mg BD oral/IV If suspected MRSA add: TEICOPLANIN IV 12 hourly for 4 doses then OD Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l Total treatment duration (including oral step-down): 7-14 days

LEVOFLOXACIN 500mg BD oral/IV (oral route preferred. Consider reducing to 500mg daily if patient clearly improving) If suspected MRSA add: TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l Total treatment duration (including oral step-down): 7-14 days


ASPIRATION PNEUMONIA

Severity 1st



CO-AMOXICLAV 625mg TDS oral Treatment duration: 7 days

LEVOFLOXACIN 500mg BD oral (consider reducing to 500mg daily if patient clearly improving) PLUS METRONIDAZOLE 400mg TDS oral Treatment duration: 7 days

Moderate to Severe Consider transfer to the acute settings Review doses in renal impairment

TAZOCIN 4.5g IV TDS If suspected MRSA add: TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l

LEVOFLOXACIN 500mg oral/IV BD (oral route preferred. Consider reducing to 500mg daily if patient clearly improving) PLUS TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l PLUS METRONIDAZOLE 400mg TDS oral (500mg IV TDS if nil by mouth or concerns re patients ability to absorb drugs following oral administration)


HOSPITAL ACQUIRED PNEUMONIA

Infection occurring 48 hours or more after hospital admission

Infection present on admission but patient is within 10 days of a previous in-patient stay The most accurate clinical criteria for starting empirical antibiotics therapy are

New/progressive infiltrate on CXR plus 2 or more of the following clinical features

- Temperature below 36⁰C or above 38⁰C

- Leucocytosis more than 12x109/L or leucopenia less than 4x10

9/L

- Purulent respiratory secretions Hospital acquired pneumonia tends to be over diagnosed. Always review therapy with culture results at 48-72 hours. If initial diagnosis of HAP is in doubt, then consider stopping antibiotics

Severity 1st



CO-AMOXICLAV 625mg TDS oral Treatment duration: 7 days

LEVOFLOXACIN 500mg BD oral (consider reducing to 500mg daily if patient clearly improving) Treatment duration: 7 days

Moderate to Severe FIRST DOSE THEN TRANSFER Review doses in renal impairment

TAZOCIN 4.5g TDS IV If suspected MRSA add: TEICOPLANIN IV 12 hourly for 4 doses then OD Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l

LEVOFLOXACIN 500mg BD oral/IV (oral route preferred. Consider reducing to 500mg daily if patient clearly improving) PLUS TEICOPLANIN IV 12 hourly for 4 doses then OD Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l


URINARY TRACT INFECTIONS

Refer to the following organisational documents (see appendices)

- Diagnostic criteria for Urinary Tract Infection - Diagnostic criteria for catheter associated UTI - Diagnostic criteria for UTI in confused patients

Urinalysis Urinalysis only has a role in the diagnosis of UTI after initial clinical assessment of the patient. If the patient has no urinary symptoms (as listed above) then perform urinalysis to screen for, or diagnose UTI, has a very limited role. The only elements of urinalysis using dipsticks that are relevant to the diagnosis of UTI are leucocyte esterase and nitrite. Urinalysis results for protein, glucose, ketones, blood and pH have no relevance when trying to find evidence of a patient having UTI. In catheterised patients, after a few days all catheters will be colonised and many will have caused some degree of catheter irritation leading to pyuria and bacteriuria. Therefore performing urinalysis on a catheterised patient has no diagnostic value for UTI. In the elderly (over 65 years), do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity.

Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria: only treat if symptomatically unwell or pyelonephritis likely. Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma.

UNCOMPLICATED UTI IN MEN & WOMEN (no fever or flank pain) Women with severe / 3 or more symptoms: treat Women with mild / 2 or fewer symptoms: use urine dipstick and presence of cloudy urine to guide treatment. Nitrite and blood/leucocytes has 92% positive predictive value; Negative nitrite, leucocytes & blood: 76% negative predictive value. Men: Consider prostatitis and send pre-treatment MSU OR if symptoms mild/non-specific, use negative dipstick to exclude UTI.

http://nww.glospct.nhs.uk/C8/C10/Urinalysis%20Training/Document%20Library/Diagnostic%20criteria%20for%20Urinary%20Tract%20Infection%20pdf%20-%20final%20GCS.pdf

http://nww.glospct.nhs.uk/C8/C10/Urinalysis%20Training/Document%20Library/Diagnostic%20criteria%20for%20catheter%20associated%20Urinary%20Tract%20Infection%20pdf%20-%20final%20GCS.pdf

http://nww.glospct.nhs.uk/C8/C10/Urinalysis%20Training/Document%20Library/Diagnostic%20criteria%20for%20Urinary%20Tract%20Infection%20in%20confused%20pt%20pdf%20-%20final%20GCS.pdf


URINARY TRACT INFECTION (Including complicated UTI and pyelonephritis)

Severity 1st


Minor to moderate lower UTI infection

TRIMETHOPRIM 200mg BD oral OR NITROFURANTOIN 50mg QDS or NITRUFURANTOIN 100mg M/R BD oral Treatment duration: Non-pregnant women = 3 days Men and pregnant women = 7 days

Not applicable

Moderate to severe infection

GENTAMICIN IV refer to page 8 for dosing

If gentamicin is contraindicated then use:

Age 40 years or younger:

CO-AMOXICLAV 625mgTDS oral (1.2g IV TDS only if nil by mouth)

Age over 40 years: TAZOCIN 4.5g TDS IV

Treatment duration: 7 days Pyelonephritis 10-14 days

CIPROFLOXACIN 500mg BD oral Treatment duration: 7 days Pyelonephritis:10-14 days


MENINGITIS (suspected meningococcal disease)

INITIAL THERAPY PRIOR TO IMMEDIATE TRANSFER TO THE ACUTE TRUST Administration must not delay transfer

Severity 1st

line comments Adults and children 12 years and over

CEFOTAXIME 1g IV stat (or IM if vein cannot be found) PLUS DEXAMETHASONE PHOSPHATE 10mg IV stat (Note: this dose is equivalent to 8.3mg of dexamethasone base)

Transfer immediately to acute trust

Prevention of Secondary Case of Meningitis:

Only prescribe prophylaxis following advice from Public Health Doctor: 9am–5pm: 0845 504 8668

Out of hours: Contact on-call Public Health Doctor

0844 257 8195 (or via switchboard 0300 422 2222)

VIRAL MENINGO ENCEPHALITIS

THIS INITIAL THERAPY PRIOR TO IMMEDIATE TRANSFER TO THE ACUTE TRUST

Severity 1st

line comments Suspected viral meningo encephalitis e.g. due to herpes simplex or varicella zoster virus

ACICLOVIR 10mg/kg IV stat Transfer immediately to an acute trust


SKIN AND SOFT TISSUE INECTIONS

IMPETIGO

For extensive, severe or bullous impetigo use oral antibiotics.

Reserve topical antibiotics for very localised lesions to reduce the risk of resistance.

Reserve Mupirocin for MRSA

Severity 1st

line Penicillin Allergy (see explanatory notes) For localised lesions only

FUSIDIC ACID TDS topically For MRSA localised lesions only:

MUPIROCIN TDS topically Treatment duration : 5 days

For more severe/non-localised lesions

FLUCLOXACILLIN 500mg QDS oral Treatment duration: 7 days

CLARITHROMYCIN 250-500mg BD oral Treatment duration: 7 days

HERPES ZOSTER (Shingles)

Treat if over 50 years old and within 72 hours of onset of rash

Treat if under 50 years of age and active ophthalmic zoster, Ramsey Hunt or eczema

Post herpetic neuralgia is rare in under 50 year olds ACICLOVIR 800mg oral FIVE times a day for SEVEN days

VARICELLA ZOSTER (Chickenpox)

Seek urgent specialist advice if pregnant or immunocompromised

Treat if within 24 hours of start of rash AND over 14 years of age, or severe pain, or dense or oral rash, or secondary household case or patient on steroids or smoker.

ACICLOVIR 800mg oral FIVE times a day for SEVEN days

COLD SORES Cold sores resolve 7-10 days without treatment .Topical antivirals applied prodromally only reduce the duration by 12-24 hours and are not routinely indicated.


CELLULITIS

Assessment of grade of cellulitis (Eron/Dall criteria):

Class 1 Healthy patients with cellulitis, up to 15 cm diameter, with or without fever

Class 2 Healthy patients or patient with peripheral vascular disease, diabetes or obesity with cellulitis more than 15 cm with or without fever. Patient in whom oral antibiotics have failed

Class 3 Patients with fever and mental status change, physical findings of gangrene, crepitus bullae or open draining wounds (requires hospital admission)

Class 4 Patients with systemic complication of severe infection which includes hypotension, renal failure and acute respiratory distress syndrome

Severity 1st

line Penicillin Allergy (see explanatory notes) CLASS 1 or 2 (if oral antibiotics appropriate) Minor to moderate infections

FLUCLOXACILLIN 1g QDS oral PLUS AMOXICILLIN 500mg TDS oral If suspected/confirmed MRSA, use: DOXYCYCLINE 200mg ONCE DAILY oral

Treatment duration: 7-14 days

CLINDAMYCIN 450mg QDS oral STOP and review if patient develops diarrhoea

If suspected/confirmed MRSA, use: DOXYCYCLINE 200mg ONCE DAILY oral Treatment duration: 7-14 days

Class 2 (IV antibiotics appropriate) Moderate infection

BENZYLPENICILLIN 2.4g QDS IV PLUS FLUCLOXACILLIN 1g QDS IV If suspected/confirmed MRSA, initially ADD: TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l For traumatic wounds assess tetanus immune status. Consider adding: METRONIDAZOLE 400mg TDS oral or 500mg TDS IV unless using Clindamycin

CLINDAMYCIN 1.2g QDS IV STOP and review if patient develops diarrhoea If suspected/confirmed MRSA, initially ADD: TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l

Class 3 and 4 Severe Infection

BENZYLPENICILLIN 2.4g 4 hourly IV PLUS FLUCLOXACILLIN 1g QDS IV PLUS CLINDAMYCIN 1.2g QDS IV STOP and review if patient develops diarrhoea If suspected/confirmed MRSA, ADD: TEICOPLANIN IV 12 hourly for 4 doses then OD and urgently review with microbiologist Less than 50kg = 400mg

CLINDAMYCIN 1.2g QDS IV STOP and review if patient develops diarrhoea If suspected/confirmed MRSA, initially ADD: TEICOPLANIN IV 12 hourly for 4 doses then OD and urgently review with microbiologist Less than 50kg = 400mg


50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l

50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l

FACIAL CELLULITIS

Severity 1st

line Penicillin Allergy (see explanatory notes) Facial cellulitis

CO-AMOXICLAV 625mg TDS oral Treatment duration: 7 -14 days

CLINDAMYCIN 450mg QDS oral Treatment duration: 7 -14 days Stop and review if patient develops diarrhoea

PERIORBITAL CELLULITIS

Severity 1st

line Penicillin Allergy (see explanatory notes) PERIORBITAL CELLULITIS

CEFTRIAXONE 2g BD IV plus CLINDAMYCIN 1.2g QDS IV

STOP and review if patient develops diarrhoea

If suspected/confirmed MRSA, initially

ADD:

TEICOPLANIN IV 12 hourly for 4 doses then OD and urgently review with microbiologist Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l

LINEZOLID 600mg BD IV/orally plus CIPROFLOXACIN 750mg BD orally plus METRONIDAZOLE 400mg TDS orally or 500mg TDS IV if nil by mouth or concerns re patients ability to absorb drugs following oral administration If suspected/confirmed MRSA, note LINEZOLID has activity against MRSA


LEG ULCERS AND DIABETIC ULCERS WITHOUT OSTEOMYELITIS

Bacteria will always be present. Antibiotics do not improve ulcer/would healing unless there is active infection

Indicators of active infection include- inflammation, redness, cellulitis, increased pain, purulent exudates, new offensive odour, rapid deterioration or pyrexia

Cultures and swabs are only indicated if diabetic or evidence of clinical infection (as above)

Sampling for culture requires cleaning then vigorous curettage and aspiration. Any swabs should be taken from the infected edge of the ulcer not the middle

For cellulitis around a leg ulcer treat as for cellulitis

Severity 1st

line Penicillin Allergy (see explanatory notes) Minor to moderate

CO-AMOXICLAV 625mg TDS oral If suspected/confirmed MRSA, use: DOXYCYCLINE 200mg ONCE DAILY oral

CLINDAMYCIN 450mg QDS oral STOP and review if patient develops diarrhoea If suspected/confirmed MRSA, use: DOXYCYCLINE 200mg ONCE DAY oral

Moderate to severe

TAZOCIN 4.5g TDS IV

If suspected/confirmed MRSA, initially ADD:

TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY and urgently review with microbiologist Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l

CIPROFLOXACIN 500mg BD oral PLUS CLINDAMYCIN 1.2g QDS IV STOP and review if patient develops diarrhoea If suspected/confirmed MRSA, initially ADD: TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY and urgently review with microbiologist Less than 50kg = 400mg 50-100kg = 600mg Greater than 100kg = 800mg Maintain treatment pending pre-dose (trough) levels on day 5 Target level 15-60mg/l


OSTEOMYELITIS/SEPSIS ARTHRITIS NATIVE JOINTS (NON HIGH RISK)

SEPTIC ARTHRITIS REQUIRES URGENT REFERRAL TO ORTHOPAEDIC SURGEON FOR WASHOUT

Treatment should be discussed with a microbiologists and adjusted according to culture results

THIS IS INITIAL THERAPY AND THE PATIENT MUST BE TRANSFERRED TO AN ACUTE

SETTING AS SOON AS POSSIBLE

Severity 1st


REMEMBER SAMPLES BEFORE TREATMENT

Minor to severe life threatening infection

BENZYLPENICILLIN 2.4g QDS IV PLUS FLUCLOXACILLIN 2g QDS IV PLUS consider adding RIFAMPICIN 450mg BD oral for severe infection if no contra-indication. (Monitor liver function) If suspected/confirmed MRSA microbiologist MUST be consulted

Continue IV antibiotics for a minimum of 14 days then discuss oral therapy with microbiologist and continue for a further 28 days (Minimum total 6 weeks)

CLINDAMYCIN 1.2g QDS IV

STOP and review if patient develops diarrhoea PLUS consider adding RIFAMPICIN 450mg BD oral for severe infection if no contra-indication. (Monitor liver function) If suspected/confirmed MRSA microbiologist MUST be consulted

Continue IV antibiotics for a minimum of 14 days then discuss oral therapy with microbiologist and continue for a further 28 days (Minimum total 6 weeks)


OSTEOMYELITIS/SEPSIS ARTHRITIS NATIVE JOINTS

(HIGH RISK. e.g. Immunocompromised, rheumatoid arthritis, diabetes [note: separate guideline for diabetic ulcer with associated osteomyelitis], injecting drug users or patients with catheter related

bloodstream infections))

SEPTIC ARTHRITIS REQUIRES URGENT REFERRAL TO ORTHOPAEDIC SURGEON FOR WASHOUT

Treatment should be discussed with a microbiologists and adjusted according to culture results

THIS IS INITIAL THERAPY AND THE PATIENT MUST BE TRANSFERRED TO AN ACUTE

SETTING AS SOON AS POSSIBLE

Severity 1st


REMEMBER SAMPLES BEFORE TREATMENT

Minor to severe life threatening infection

FLUCLOXACILLIN 2g QDS IV plus RIFAMPICIN 450mg BD oral (Monitor liver function) plus CIPROFLOXACIN 750mg BD oral

If suspected/isolated MRSA microbiologist MUST be consulted. Continue IV antibiotics for a minimum of 14 days then discuss oral therapy with microbiologist and continue for a further 28 days (Minimum total 6 weeks)

CLINDAMYCIN 1.2g QDS IV STOP and review if patient develops diarrhoea plus CIPROFLOXACIN 750mg BD oral plus consider adding RIFAMPICIN 450mg BD Oral for severe infection if no contra-indication. (Monitor liver function)

If suspected/isolated MRSA microbiologist MUST be consulted. Continue IV antibiotics for a minimum of 14 days then discuss oral therapy with microbiologist and continue for a further 28 days (Minimum total 6 weeks)

CONJUNCTIVITIS

Severity 1st

line

Mild Treat only if severe, as most infections are viral or self-limiting

Severe

CHLORAMPHENICOL 0.5% drops 2 Hourly for 2 days reducing to 4 hourly (only while the patient is awake) PLUS CHLORAMPHENICOL 1% Eye ointment at NIGHT OR FUSIDIC ACID 1 % Eye Gel apply TWICE a day Duration: for 48 hours after resolution

http://intranet/en/Trust-Staff/Antibiotic-Guidelines/SkinSoft-tissueBoneJoint/Diabetic-Ulcers/


GASTROINTESTINAL INFECTIONS

INTRA-ABDOMINAL SEPSIS, PERITONITIS AND DIVERTICULITIS

Severity 1st


Non-severe

Antibiotic therapy may not be required. Consider a period of observation. If treatment is indicated - see below

Moderate to severe life threatening infection

If severe initial therapy only then transfer to the acute trust as soon as possible

AMOXICILLIN 1g TDS IV plus METRONIDAZOLE 500mg TDS IV plus GENTAMICIN daily IV OR If gentamicin is contra-indicated then use: TAZOCIN 4.5g TDS IV (monotherapy)

If gross faecal contamination of peritoneum, consider adding METRONIDAZOLE 500mg TDS IV

Duration: 5 - 7 days according to clinical response

Non-Severe Penicillin Allergy:

MEROPENEM 1g TDS IV

If gross faecal contamination of peritoneum, consider adding METRONIDAZOLE 500mg TDS IV Severe Penicillin Allergy:

TIGECYCLINE 100mg IV stat as loading. Then 50mg BD IV (25mg BD in severe hepatic disease) plus GENTAMICIN daily IV

If gross faecal contamination of peritoneum, consider adding METRONIDAZOLE 500mg TDS IV


IV to Oral Switch

CO-AMOXICLAV 625mg TDS oral (monotherapy) unless lab results indicate otherwise


CIPROFLOXACIN 500mg BD oral plus METRONIDAZOLE 400mg TDS oral unless lab results indicate otherwise





BILIARY TREE

Severity 1st


Minor to moderate infection

Antibiotic therapy may not be required. Consider a period of observation. If treatment is indicated see schedule B

Not Applicable

Moderate to severe infection (Review doses in renal impairment)

CIPROFLOXACIN 750mg BD oral Duration 5-7 days

Not Applicable

Severe life threatening infection (Review doses in renal impairment)

If evidence of sepsis or patient is NBM TAZOCIN 4.5g TDS IV Duration 5-7 days

Non-Severe Penicillin Allergy: MEROPENEM 1g TDS IV Severe Penicillin Allergy: If oral antibiotics tolerated and patient absorbing, use: CIPROFLOXACIN 750mg BD oral plus METRONIDAZOLE 400mg TDS oral If intravenous antibiotics required, use: CIPROFLOXACIN 400mg BD IV plus METRONIDAZOLE 500mg TDS IV

IV to Oral Switch

CIPROFLOXACIN 750mg BD oral plus

METRONIDAZOLE 400mg TDS oral

For a total of 7 days therapy unless lab results indicate otherwise

N.B. Avoid co-amoxiclav for biliary tract sepsis due to risk of cholestatic jaundice

http://intranet/en/Trust-Staff/Antibiotic-Guidelines/Renal/







SPONTANEOUS BACTERIAL PERITONITIS

Transfer to an acute hospital is likely to be required for on-going management

Severity 1st


Minor to severe

infection

TAZOCIN 4.5g TDS IV (monotherapy)

Treatment duration: 5 - 7 days according to clinical response. Then see IV to Oral Switch below (unless lab results indicate otherwise)

Non-Severe Penicillin Allergy: MEROPENEM 1g TDS IV

Severe Penicillin Allergy:

TIGECYCLINE 100mg IV stat as loading. Then 50mg IV BD (25mg BD in severe hepatic

disease) plus

GENTAMICIN IV (as per local protocol)

Treatment duration: 5 - 7 days according to clinical response. Then see IV to Oral Switch below (unless lab results indicate otherwise)

IV to oral switch

CO-AMOXICLAV 625mg TDS oral

Treatment duration: 5 - 7 days according to clinical response.

Note: Discuss need for ongoing antibiotic prophylaxis with

Gastroenterologist

CIPROFLOXACIN 500mg BD orally plus METRONIDAZOLE 400mg TDS orally

Treatment duration: 5 - 7 days according to clinical response.

Discuss need for ongoing antibiotic prophylaxis with Gastroenterologist



http://intranet/en/Trust-Staff/Antibiotic-Guidelines/Gentamicin-Protocol/


CLOSTRIDIUM DIFFICILE INFECTION (CDI) in adults

Healthcare workers should use the ‘SIGHT’ mnemonic when managing suspected potentially infectious diarrhoea. Use the Bristol Stool Chart to monitor frequency and severity of

diarrhoea

S Suspect that the diarrhoea may have an infective cause where there is no clear alternative cause for diarrhoeas (drugs e.g. laxative, underlying bowel disease)- if you suspect CDI on clinical grounds, start treatment for CDI empirically pending test results and then review that treatment when the results become available

I Isolate the patient immediately- consult the infection control team whilst determining the cause of the diarrhoea

G Gloves and aprons must be used for all contacts with the patient and their environment

H Hand washing with soap and water must be carried out before and after each contact with the patient and the patient’s environment

T Test the stool for evidence of toxigenic Clostridium Difficile, by sending a specimen immediately


Table 1: Initial assessment and management

If CDI is suspected, send a stool (faeces) specimen to the microbiology lab and start antibiotic treatment immediately (see table 2). Review CDI therapy if initial test result is negative. If symptoms continue despite a negative result and clinical suspicion of CDI remains, send a further stool specimen for testing after 5 days. Repeat CDI testing during therapy or as a ‘test of cure’ is not required

Assess clinical severity of CDI at diagnosis and then daily Mild CDI: not associated with a raised WCC; typically associated with less than 3 stools of type 5-7 per day Moderate CDI: associated with a raised WCC less than 15 x10

9 /L; typically with 3-5 stools per day

Severe CDI: if any of the following:

White blood cell count greater than 15x109/L Temperature greater than 38.5°C

Albumin less than 20g/L CRP greater than 200

Acutely rising serum creatinine (e.g. greater than 50% increase above baseline

Evidence of severe colitis (abdominal signs, radiology, endoscopy)

Life threatening CDI if any of hypotension, ileus, toxic megacolon, CT evidence of severe disease. Notes for severe/life threatening CDI:

1. Request early gastroenterology and/or surgical and/or critical care review 2. The number of stools may be a less reliable indicator of severity

Isolate patient in single room Fluid and electrolyte replacement and nutrition review as necessary

Review current therapy: 1. Stop antibiotics and other drugs that might cause diarrhoea if possible 2. stop PPIs/H2 antagonists unless required acutely

Avoid anti-motility drugs (e.g. loperamide)

Table 2: Specific Antibiotic Therapy

First episode of mild/moderate severity

METRONIDAZOLE 400mg TDS oral for 10-14 days If nil by mouth use: METRONIDAZOLE 500mg TDS IV for 10-14 days If increasing severity of CDI OR no response to therapy within 7 days, change to: VANCOMYCIN 125mg oral or via NG tube QDS for 10-14 days Note: Patients with mild disease may not require specific C difficile antibiotic treatment

First episode of severe disease

VANCOMYCIN 125mg oral or via NG tube QDS for 10-14 days If evidence of severe CDI continues or worsens:

ADD in metronidazole 500mg IV TDS + increase vancomycin dose to 250mg oral/ NG QDS

Discuss potential additional/alternative therapy with consultant medical microbiologist

Obtain surgical/gastroenterology/critical care review as appropriate

Second episode of CDI

Assess severity as above, if assessed as sever CDI then manage as severe disease above Review medication; stop any predisposing antibiotics., PPIs/H2 antagonists if possible In non-severe disease commence VANCOMYCIN 125mg oral or via NG tube QDS for 10-14 days If poor response discuss potential alternative therapy with consultant medical microbiologist

Subsequent episode of CDI i.e. third or more episode

Assess severity as above, if assessed as severe CDI then manage as severe disease (see above) Review medication; stop any predisposing antibiotics., PPIs/H2 antagonists if possible In non-severe disease commence VANCOMYCIN 125mg oral or via NG tube QDS pending discussion with consultant medical microbiologist regarding potential additional/alternative therapy Obtain gastroenterology review


GENITAL TRACT INFECTIONS

PELVIC INFLAMMATORY DISEASE A low threshold for empirical treatment of PID is recommended because of the lack of definitive clinical diagnostic criteria and because the potential consequences of not treating of PID are significant. The following clinical features are suggestive of a diagnosis of PID:

bilateral lower abdominal tenderness (sometimes radiating to the legs)

abnormal vaginal or cervical discharge

fever (greater than 38°C)

abnormal vaginal bleeding (intermenstrual, postcoital or 'breakthrough')

deep dyspareunia

cervical motion tenderness on bimanual vaginal examination

adnexal tenderness on bimanual vaginal examination (with or without a palpable mass).

Severity 1st


Minor to moderate infection

CEFTRIAXONE 500mg IM stat Followed by: DOXYCYCLINE 100mg BD oral plus METRONIDAZOLE 400mg BD oral Treatment duration: 14 days

AZITHROMYCIN 1g oral stat Followed by: OFLOXACIN 400mg BD oral plus METRONIDAZOLE 400mg BD oral Treatment duration: 14 days

Moderate to severe infection (Review doses in renal impairment)

CEFTRIAXONE 2g DAILY IV

plus DOXYCYCLINE 100mg BD oral plus METRONIDAZOLE 500mg TDS IV (or 400mg TDS oral if oral antibiotics tolerated and patient absorbing

AZITHROMYCIN 1g stat oral followed by: CLINDAMYCIN 900mg TDS IV plus GENTAMICIN Daily IV (as per local protocol)

IV to Oral Switch

DOXYCYCLINE 100mg BD oral plus METRONIDAZOLE 400mg BD oral To complete 14 days

CLINDAMYCIN 450mg QDS oral plus OFLOXACIN 400mg BD oral To complete 14 days

EPIDIDYMO-ORCHITIS

Severity 1st

line For epididymo-orchitis most probably due to any sexually transmitted pathogen:

CEFTRIAXONE 500mg IM stat PLUS DOXYCYCLINE 100mg BD orally for 14 days

If most probably due to chlamydia or other non-gonococcal

organisms)

DOXYCYCLINE 100mg BD oral for 10-14 days Or OFLOXACIN 200mg BD oral for 14 days

PROSTATITIS

Severity 1st

line

Acute prostatitis:

CIPROFLOXACIN 500mg BD orally Or OFLOXACIN 200mg BD orally Duration: 28 days 2

nd line

TRIMETHOPRIM 200mg BD orally Duration: 28 days




MRSA TREATMENT

MRSA can cause infection at any site. Deep seated infections e.g. osteomyelitis may not respond to antibiotics alone and may need surgical intervention. Skin and soft tissue infection and UTI or RTI

Total daily dose dependant on severity of infection

Severe soft tissue infection may require up to 3 weeks of antibiotics

For osteomyelitis or septic arthritis please consult a microbiologist

First line if sensitive

DOXYCYCLINE 200mg once daily oral for 7-10 days

Second line if sensitive RIFAMPICIN 600mg daily or BD oral for 7-10 days Plus FUSIDIC ACID 500mg TDS oral for 7-10 days

TEICOPLANIN IV 12 hourly for 4 doses then ONCE DAILY and urgently review with microbiologist OR if sensitive CLINDAMYCIN 450mg QDS oral for 7-10 days (stop if diarrhoea occurs)

MRSA SUPPRESSION (Decolonisation)

MUPIROCIN 2% nasal ointment TDS topically to each nostril for 5 days PLUS 4% CHLORHEXIDINE GLUCONATE (HIBISCRUB) bodywash as soap in bath or shower DAILY for 5 days Second line if the patient has irritant dermatitis; OCTENISAN body-wash/shampoo. DAILY for 5 days Moisten skin and apply undiluted antiseptic then rinse. Particularly apply to know carriage sites axilla, groin & perineum). Wash hair using antiseptic body-wash/shampoo at least twice during the 5 days See Gloucestershire Care Services NHS Trust Infection Control Policy for the Prevention and Control of MRSA Policy on the intranet for further information.

antibiotic guidelines for inpatients solely local ... · gloucestershire care services inpatient...

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