Information for Clinicians Microbiology Department

Information for Clinicians
Microbiology Department
Guideline for the Empirical Treatment of Infections in Adults
______________________________________________________________________
Appropriate prescribing of antibiotics
Decision to prescribe
The use of antibiotics carries significant risks to the patient and the decision to prescribe
an antibiotic should always be clinically justified following a risk-benefit assessment. Do
not start antibiotics in the absence of clinical evidence of bacterial infection unless the
patient is gravely ill and sepsis is part of the differential diagnosis. If the clinical picture
is not clear and the patient is stable, it may be possible to wait, monitor the patient
clinically and review with laboratory results.
If there is evidence/suspicion of sepsis, use local guidelines to initiate broad spectrum
antibiotic treatment within one hour of diagnosis (or as soon as possible) in patients with
life threatening infections. Delay in starting adequate antibiotic therapy in severe
infection is associated with increased morbidity and mortality. Individual patient and
drug-specific factors to consider in all cases include:
• previous antimicrobial history
• previous colonisation or infection with multi-resistant organisms
• allergies and other side effects (including risk of Clostridium difficile infection)
• contraindications and cautions
• availability of and absorption by oral route
Appropriate specimens for microscopy, culture and sensitivity should be obtained prior
to commencing antibiotics wherever possible but do not delay starting treatment in
patients who are severely ill.
Minimising the use of broad-spectrum antibiotics
The use of broad-spectrum antibiotic agents is a major factor in inducing C. difficile
infection. In addition there is evidence to show an association between total
antimicrobial use and use of some specific classes of antibiotics with higher MRSA
prevalence. Clinicians should avoid the use of cephalosporins, quinolones, broadspectrum penicillins (including amoxicillin) and clindamycin unless there are clear
clinical indications for their use.
Broad-spectrum antibiotics should be restricted to the treatment of serious infections
when the pathogen is not known or when other effective agents are unavailable.
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 1 of 26
Documentation
The clinical indication, duration or review date, route and dose should be clearly
documented in the patient’s medical notes and on the drug chart.
Reasons for any deviations from empirical treatment guidelines should be recorded in
the patient’s medical notes.
Allergies must be recorded in the patient’s medical notes and on the front of the drug
chart and anaesthetic record, along with the nature of the reaction.
Review of antibiotic treatment
Review the clinical diagnosis and the continuing need for antibiotics by 48 hours then
daily with a clear plan of action - the “Antimicrobial Prescribing Decision”. The five
Antimicrobial Prescribing Decision options are:
1.
Stop antibiotics if there is no evidence of infection
2.
Switch IV to Oral
3.
Change antibiotics – ideally to a narrower spectrum – or broader if required
4.
Continue and review again after a further 24 hours
5.
Outpatient Parenteral Antibiotic Therapy (OPAT)
It is essential that the review and subsequent decision is clearly documented in the
medical notes. Treatment with antibiotics should not continue beyond 7 days (IV and
oral) unless recommended by a local guideline or microbiologist.
Department of Health Guidance recommend a Start Smart - then Focus approach for all
antibiotic prescriptions
Start smart is:
• Do not start antibiotics in the absence of clinical evidence of bacterial infection
• If there is evidence/suspicion of bacterial infection, use local guidelines to initiate
prompt effective antibiotic treatment
• Document on drug chart and in medical notes: clinical indication, duration or review
date, route and dose
• Obtain cultures first
• Prescribe single dose antibiotics for surgical prophylaxis; where antibiotics have
been shown to be effective
Then focus is:
• Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and
make a clear plan of action - the “Antimicrobial Prescribing Decision”
• The five Antimicrobial Prescribing Decision options are:
- Stop antimicrobials
- Switch IV to Oral
- Change,
- Continue
- Outpatient Parenteral Antibiotic Therapy (OPAT).
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 2 of 26
Intravenous or oral therapy
Intravenous (IV) therapy should only be used for patients with severe infections,
patients who have a focus of infection requiring high doses of antibiotics, patients who
are unable to take or absorb oral antibiotics, and when there are no alternative suitable
oral agents.
IV antibiotics should be reviewed on a daily basis and, if appropriate, the patient
switched to an oral equivalent within 24 hours of meeting switch criteria.
Oral switch criteria are:
•
•
•
•
•
•
temperature < 37.5 °C for 24 hours
signs and symptoms of infection are improving
inflammatory markers are decreasing
patient able to tolerate oral food and fluids
absence of on-going or potential problem of absorption
oral formulation or suitable oral alternative is available
Exceptions to this include some serious infections where exceptionally high antibiotic
tissue concentrations are essential (e.g. meningitis, infective endocarditis) or following
microbiological advice.
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 3 of 26
Using this guideline
This antibiotic policy gives initial empirical treatment only but should be used
discriminately with consideration of contra-indications, interactions and previous culture
results. Doses are based on normal hepatic and renal function in a 70kg man and
may require adjustment. Durations are given as a guide but should be evaluated
based on the condition being treated & the clinical response. Antibiotics should be
reviewed and rationalised with microbiology results and clinical progress.
•
•
•
•
•
Vancomycin and Gentamicin - Always check levels at appropriate intervals and
adjust dose / dosage interval accordingly. See “Guidelines for the dosing and
monitoring of Gentamicin, Vancomycin and Teicoplanin” for further advice. Do not
use Gentamicin for more than 7 days without discussion with a Microbiologist.
Penicillin allergy - patients with a history of anaphylaxis, urticarial rash or a rash
immediately after penicillin administration (type 1 allergy) should not receive a
penicillin, cephalosporin or other beta-lactam antibiotic. Check before prescribing if
you are unsure which class an antibiotic belongs to. Discuss alternative antibiotic
treatment with a Microbiologist if a suitable one is not given in the policy.
MRSA - If a patient has been in hospital for more than five days, has previously
been known to be colonised with MRSA, or is at risk for MRSA colonisation (e.g.
recent hospital admission or resident in a Nursing or Residential home) consider
using Vancomycin or Teicoplanin.
Extended Spectrum Beta-Lactamase (ESBL) producers, Vancomycin Resistant
Enterococci (VRE) and other multi-resistant organisms - If a patient has been
previously colonized or infected with a multi resistant organism or may have risk
factors for colonisation (e.g. recurrent urinary tract infections, admitted from a
nursing home or a long term catheter in situ) an alternative antibiotic regime may be
necessary– discuss with Microbiology.
Tetanus - for further information see ‘Immunisation Against Infectious Diseases The Green Book’ December 2006, Chapter 30: Tetanus.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAn
dGuidance/DH_079917
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 4 of 26
Empirical Treatment Guidelines
Adult Empirical Treatment Guidelines: Sepsis (antibiotics should be initiated within 1 hour of diagnosis)
Infection
Antibiotic Treatment IV Option
Comments
Community-acquired
sepsis of unknown
origin, meningitis not
suspected
Co-amoxiclav 1.2g tds &
Gentamicin 5mg/kg od
+/- Metronidazole 500mg tds if
anaerobic infection suspected
If neutropenia or suspected neutropenia,
see Neutropenic Sepsis Guideline
Penicillin allergy:
Teicoplanin 600mg 12 hourly for
first 3 doses then 600mg od &
Gentamicin 5mg/kg od
+/-Metronidazole 500mg tds if
anaerobic infection suspected
Hospital acquired
sepsis
If ESBL producer or other multi-resistant
organism present, or if concern regarding
clinical response or renal function, discuss with
Microbiology
Discuss all cases with Microbiology within 24
hours
Discuss with Microbiology
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval
accordingly. See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Adult Empirical Treatment Guidelines: CNS Infections
Infection
Suspected Bacterial
Meningitis
Antibiotic Treatment IV Option
Ceftriaxone 4g od
Add Amoxicillin 2g
4 hourly if patient >50 years old or if
immunocompromised or pregnant
Discuss with Microbiology if recent
travel abroad or penicillin allergy
Comments
Consider adjunctive dexamethasone
(0.15 mg/kg 4 hourly for 2–4 days with the first
dose administered 10–20 min before, or at least
concomitant with, the first dose of antimicrobial
therapy) in adults with suspected or proven
pneumococcal meningitis
Discuss all suspected cases with a
Microbiologist
Inform relevant Health Protection Unit (via
switchboard)
Send EDTA blood sample for Meningococcal
and Pneumococcal PCR
Treat for 14-21 days
Suspected HSV
encephalopathy
Aciclovir 10mg/kg tds
Dose reduction required if
eGFR<50
Inform relevant Health Protection Unit (via
switchboard)
CSF should be sent for viral PCR
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 5 of 26
Adult Empirical Treatment Guidelines: Genitourinary
• Previous urine culture results should guide empirical therapy
• Review with urine culture results
• Urine dipsticks are often positive in elderly patients and treatment may not be indicated – see UTI in the Non
Catheterised Older Adult Guidelines
Infection
Antibiotic Treatment
Total
Duration
Additional Comments
3 days
Nitrofurantoin is contra-indicated
in patients with eGFR <20ml/min
and may be ineffective if eGFR
20-60ml/min
Trimethoprim 200mg po bd
Uncomplicated
UTI in
women (See UT
I in the non
catheterised
Older Adult
Guidelines
If recent Trimethoprim use or known
Trimethoprim resistant isolate:
Co-amoxiclav 625mg po tds
Penicillin allergy: Nitrofurantoin 50mg po qds
Trimethoprim 200mg po bd
UTI in
men (See UTI
in the non
catheterised
Older Adult
Guidelines
Mild UTI in
pregnancy
Pyelonephritis
Urinary Catheter
Infection
(Urinary
symptoms,
fever, sepsis, ↑
inflammatory
markers).
7 days
If recent Trimethoprim use or known
Trimethoprim resistant isolate:
Co-amoxiclav 625mg po tds
Discuss with Microbiology if
there is high risk of, or previous
infection/ colonisation with a
VRE, ESBL producing isolate, or
other multi-resistant organism
Penicillin allergy: Nitrofurantoin 50mg po qds
Cefalexin 500mg po bd
IV treatment:
Co-amoxiclav
1.2g tds & single
dose of
Gentamicin
5mg/kg
Penicillin allergy:
Ciprofloxacin
500mg po bd
& single dose of
Gentamicin
5mg/kg iv
Amoxicillin1g tds
& Gentamicin
5mg/kg od
Oral treatment:
Co-amoxiclav 625mg
tds
Penicillin allergy:
Ciprofloxacin 500mg bd
(7 days treatment only
required if ciprofloxacin
used)
Oral treatment not
recommended for
empirical treatment
7 days
10-14
days
Repeat MSU 7 days after
completion of antibiotics as test
of cure
Discuss with Microbiology if
there is high risk of, or previous
infection/ colonisation with a
VRE, ESBL producing isolate, or
other multi-resistant organism
7 days
Review oral switch with culture
results and clinical progress
7 days
Penicillin allergy:
Gentamicin
5mg/kg once daily
& single dose of
Vancomycin 1g
Discuss with Microbiology if
there is high risk of, or
previously infection/ colonisation
with a VRE, ESBL producer, or
other multi-resistant organism
Consider catheter change once
antibiotic known to be active
against isolate
Please ensure that symptoms
are clearly indicated on the
request form for CSU culture
Adult Empirical Treatment Guidelines: Genitourinary
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 6 of 26
Infection
Antibiotic Treatment
Asymptomatic
bacterial
colonisation of
urinary catheter
No treatment required
Epididymoorchitis STI
suspected
Ceftriaxone 500mg im single dose &
Doxycycline 100mg po bd for 14 days
OR
If likely due to chlamydia or other nongonococcal organisms:
Doxycycline 100mg po bd or
Ofloxacin 200mg po bd
OR
If severe epididymo-orchitis or features
of bacteraemia, Ceftriaxone 1g iv od &
Gentamicin 5mg/kg iv od for 3-5 days
until fever subsides, and then review
with culture
OR
Ofloxacin 200mg po bd
If systemically well
Ciprofloxacin 500mg po bd
Epididymoorchitis STI not
suspected
Total
Duration
Additional Comments
Urinalysis for leukocytes &
nitrites is non-specific in CSUs
14 days
Refer to GUM
10 days
If severe epididymo-orchitis or features
suggestive of bacteraemia, Ceftriaxone
1g iv od & Gentamicin 5mg/kg iv od for
3-5 days until fever subsides, and then
review with culture results
Bacterial
Prostatitis STI not
suspected
Ciprofloxacin 500mg po bd
28 days
If STI suspected, refer to GUM
Review with culture results
Urethritis, Epididymo-orchitis, Prostatitis:
If STI suspected refer to GUM for investigation and treatment (Ext 4558)
Out of hours take (1) urethral swab for gonorrhoea culture (2) first void urine or urethral swab for chlamydia and
gonorrhoea NAAT (3) MSU for culture, and then start antibiotics. Refer to GUM for follow up.
Change of long term indwelling urethral catheter in males
• Prophylactic antibiotics are recommended in patients with a history of catheter-associated urinary tract
infection following catheter change, or if catheter change likely to be traumatic.
• Be guided by culture results of pre-change CSU (please state indication for culture clearly on request form).
If empirical cover necessary, give Gentamicin 1.5mg/kg iv or im
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval
accordingly. See ”Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Adult Empirical Treatment Guidelines: Infective Endocarditis (IE)
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 7 of 26
Infection
Antibiotic Treatment IV
Option
Comments
Infective Endocarditis: indolent
presentation
Amoxicillin 2g iv 4 hourly &
Gentamicin 1mg/kg (ideal body
weight) iv bd
Discuss all suspected cases with a
Microbiologist within 24hours,
particularly if critically ill
It is preferable to wait for blood
culture results before
commencing treatment
Take 3 sets of blood cultures from
separate venepunctures before
commencing treatment
Send a clotted sample for baseline
atypical endocarditis serology
Infective Endocarditis: acute
presentation (or indolent
presentation with penicillin allergy)
with no risk factors for
multi-resistant bacteria
Vancomycin iv dosed
according to local guidelines &
Gentamicin 1mg/kg (ideal body
weight) iv bd. If eGFR <45 use
Ciprofloxacin 750mg po bd/
400mg iv bd 12 hourly instead
of Gentamicin
Infective Endocarditis: prosthetic
heart valve or suspected MRSA
Vancomycin dosed according
to local guidelines &
Gentamicin 1mg/kg ideal body
weight 12 hourly & rifampicin
300-600mg 12 hourly po/iv
(use lower dose of rifampicin if
severe renal impairment)
TARGET LEVELS in treatment of IE:
• Vancomycin:
Pre-dose 10-15mg/l but higher
levels may be required (discuss
with Microbiology)
•
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Gentamicin:
Pre-dose: <1mg/l
Post dose 3-5mg/l
Version: 1.0
Approved on: 2013
Review date: 2016
Page 8 of 26
Adult Empirical Treatment Guidelines: Respiratory Tract
CURB-65 Guidelines to determine management of Community Acquired Pneumonia (CAP)
Markers of Severity
Confusion: new disorientation in person place or time or MTS of 8 or less
Urea: raised >7mmol/L
Respiratory rate raised ≥30/min
Blood pressure: systolic <90mmHg and/or diastolic ≤ 60mmHg
65 years old or above
0-1
2
3 or more
Low Severity
Moderate Severity
High Severity
Infection
Non-severe
exacerbations of
COPD
Low severity
CAP
Based on
clinical
judgement and
CURB-65
Moderate
severity CAP
High severity
CAP
Use iv
treatment
initially
Antibiotic
Antibiotic Treatment Oral
Treatment IV
Option
Option
Treat as low severity Community Acquired
Pneumonia
Total
Duration
Amoxicillin 1g tds
Penicillin allergy or
recent Amoxicillin:
Clarithromycin
500mg po/iv bd
5 days
Use IV only if unable to
swallow or absorb orally
If there is a high clinical
suspicion of pneumonia
caused by atypical
pathogens (including
legionella) add
Clarithromycin 500mg bd to
Amoxicillin
7-10 days
Treat with Co-amoxiclav 1.2g
iv tds instead of Amoxicillin if
recent Amoxicillin use in the
community
Amoxicillin 1g tds
& Clarithromycin
500mg po/iv bd
Penicillin allergy:
Vancomycin dosed
according to local
guidelines &
Clarithromycin
500mg po/iv bd
Co-amoxiclav 1.2g
tds
& Clarithromycin
500mg iv bd
Penicillin allergy:
Vancomycin dosed
according to local
guidelines &
Clarithromycin
500mg iv bd (if preexisting chest
disease, consider
using Ciprofloxacin
in place of
Clarithromycin)
Amoxicillin 500mg tds
Penicillin allergy or recent
Amoxicillin:
Doxycycline
200mg on day 1 then 100mg
od
OR
continue Clarithromycin
500mg bd if switching from IV
Amoxicillin 500mg tds
& Clarithromycin 500mg bd
Penicillin allergy: Doxycycline
200mg day 1 and then
100mg od
OR
continue Clarithromycin
500mg bd if switching from IV
Follow on from iv treatment:
Co-amoxiclav 625mg tds &
Clarithromycin 500mg bd
Additional Comments
5 days
Send urine for legionella
antigen
7 - 10
days
Follow on from iv treatment if
Penicillin allergy:
Doxycycline 200mg on day 1
then 100mg od
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
If MRSA pneumonia
suspected add iv
Vancomycin
Send urine for legionella
antigen and pneumococcal
antigen
Version: 1.0
Approved on: 2013
Review date: 2016
Page 9 of 26
Infection
Aspiration
pneumonia
(inpatient < 48
hours)
Aspiration
pneumonia
(inpatient >48
hours)
Infective
exacerbation of
bronchiectasis,
CF or other
suppurative lung
condition
CAP pregnancy
or breast
feeding
HAP
(Hospital < 5
days and no
previous
antibiotics)
Antibiotic
Antibiotic Treatment Oral
Treatment IV
Option
Option
Co-amoxiclav 1.2g
Amoxicillin 500mg po tds
tds
Penicillin allergy:
Clarithromycin 500mg po/iv BD &
Metronidazole po/iv tds
Co-amoxiclav 1.2g
Co-amoxiclav 625mg tds
tds
Penicillin allergy:
Clarithromycin 500mg po/iv BD &
Metronidazole po/iv tds
Discuss with
Discuss with Respiratory/
Respiratory/
Microbiology
Microbiology
Cefuroxime 1.5g
tds &
Clarithromycin
500mg po / iv bd
Penicillin allergy:
Discuss with
Microbiology
Co-amoxiclav 1.2g
tds
Penicillin allergy:
Vancomycin iv
dosed according to
local guidelines
& Ciprofloxacin po
500mg bd (or
400mg iv bd if oral
route not
appropriate)
Amoxicillin 500mg tds &
Clarithromycin 500mg bd
Penicillin allergy:
Clarithromycin 500mg bd
Discuss with Microbiology if
concerns
Co-amoxiclav 625mg tds
Total
Duration
Additional Comments
5-10 days
5-10 days
Note that in the first 48 hours
post aspiration, the patient
may present with chemical
pneumonitis for which
antibiotics are not indicated
According
to clinical
response
If suspected lung abscess,
necrotising pneumonia or
patient very unwell , discuss
with Microbiology
Empirical therapy depends
upon culture results. Two
agents may be required.
5 -10
days
Send urine for legionella
antigen
7 - 10
days
Penicillin allergy:
Discuss with Microbiology
Treat with Co-amoxiclav
625mg po tds instead of
Amoxicillin if recent
Amoxicillin use in the
community
Add Vancomycin iv dosed
according to local
guidelines if MRSA
suspected
Send legionella urinary
antigen and discuss with
Microbiology if any history
suggestive of legionella
If not responding to therapy,
discuss with Microbiology
Add Vancomycin iv dosed
PiperacillinDiscuss with Microbiology
7 - 10
according to local
tazobactam 4.5g
days
guidelines if MRSA
tds
suspected or patient very
Penicillin allergy:
unwell
Vancomycin iv
dosed according to
Send urine for legionella
local guidelines
antigen
& Ciprofloxacin po
500mg bd (or
If not responding to therapy,
400mg iv bd if oral
discuss with Microbiology
route not
appropriate)
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
HAP
(Hospital > 5
days or previous
Co-amoxiclav)
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 10 of 26
Adult Empirical Treatment Guidelines: ENT
Infection
Antibiotic
Treatment IV
Option
Antibiotic
Treatment Oral
Option
Total Duration
Additional Comments
Tonsillitis/ Quinsy
Benzylpenicillin
1.2g qds
Penicillin V 500mg
qds
10 days
Consider infectious
mononucleosis
Penicillin allergy:
Clarithromycin
500mg bd
Penicillin allergy:
Clarithromycin
500mg po bd
Ceftriaxone 2g iv
od
10-14 days
Add Metronidazole 500mg iv
tds if abscess
Penicillin allergy:
Discuss with
Microbiology
Follow on from iv
treatment:
Co-amoxiclav
625mg tds
Penicillin allergy:
Discuss with
Microbiology
Co-amoxiclav 1.2g
tds
Co-amoxiclav
625mg tds
5-7 days
Penicillin allergy:
Doxycycline 200mg
po on day 1 then
100mg po od
Use iv only if unable to
swallow or absorb po
antibiotic
OR
Epiglottitis
Acute sinusitis
Acute severe otitis
externa
Invasive otitis
externa
Flucloxacillin 1g
qds
Doxycycline 200mg
on day 1 then
100mg od
Flucloxacillin
500mg qds
Penicillin allergy or
MRSA suspected:
Vancomycin iv
dosed according to
local guidelines
Penicillin allergy:
Doxycycline 200mg
on day 1 then
100mg od
Piperacillintazobactam 4.5g
tds & Gentamicin
5mg/kg iv od
Discuss with
Microbiology
Add Metronidazole 500mg iv
tds if quinsy
According to
clinical
response
According to
clinical
response
Add Teicoplanin 600mg iv
12 hourly for first 3 doses
then 600mg iv od if MRSA
isolated or suspected
Penicillin allergy:
Discuss with
Microbiology
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 11 of 26
Adult Empirical Treatment Guidelines: Bone and Joint
Infection
Antibiotic
Treatment
IV Option
Total Duration
Additional
Comments
*********Always try to take appropriate specimens for culture prior to antibiotic therapy*********
Septic arthritis
native joint
Acute
osteomyelitis
Chronic
osteomyelitis
Diabetic foot with
possible
underlying
osteomyelitis
Flucloxacillin 2g iv Consider gonorrhoea
qds & Gentamicin
5mg/kg iv od
Please discuss with Microbiology within 1 week
Penicillin allergy:
Treatment usually requires 2 weeks iv then 4
Vancomycin iv
weeks oral antibiotics
dosed according
to local guidelines
& Ciprofloxacin
750mg po bd
Flucloxacillin 2g iv Please discuss with Microbiology within 1 week
qds & Gentamicin
5mg/kg iv od
Discuss individual case with Microbiology
If sepsis, Piperacillin-tazobactam 4.5g iv
tds. Add Vancomycin iv dosed according
to local guidelines if MRSA is suspected
If MRSA isolated or
suspected, discuss
with Microbiology
Rationalise therapy
based on results of
deep tissue culture
results
If MRO suspected, discuss with Microbiology
If not septic, discuss with Microbiology
Liaise with Diabetic Foot Team
Penicillin allergy: Discuss with
Microbiology
Suspected
prosthetic joint
infection
Vancomycin iv dosed according to local
guidelines.
Continue antibiotics until culture results are
available, then review treatment with Microbiology
Add Piperacillin-tazobactam 4.5g iv tds if
previous or suspected infection with Gram
negative organisms or patient septic or
sinus present
Penicillin allergy: Discuss with
Microbiology
Open fracture with
See Antibiotic Guideline: Surgical Prophylaxis in
Adults
and without
significant
contamination
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly.
“Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 12 of 26
Adult Empirical Treatment Guidelines: Skin and Soft Tissue
Infection
Antibiotic Treatment IV
Option
Co-amoxiclav 1.2g tds
Antibiotic Treatment
Oral Option
Co-amoxiclav 625mg tds
Penicillin allergy:
Ciprofloxacin 400mg iv bd
& Clindamycin 600mg iv
qds
Penicillin allergy:
Ciprofloxacin 500-750mg
bd & Clindamycin 300450mg qds
Cellulitis
Flucloxacillin 1g qds
Flucloxacillin 500mg qds
Penicillin allergy:
Doxycycline 200mg po on
day 1 then 100mg po od
Bursitis
Penicillin allergy or MRSA
suspected: Vancomycin iv
dosed according to local
guidelines
Flucloxacillin 1g qds
Penicillin allergy or MRSA
suspected: Vancomycin iv
dosed according to local
guidelines
Flucloxacillin 1g qds
OR
consider Co-amoxiclav
1.2g tds if breastfeeding,
post- operative or recent
Flucloxacillin
Penicillin allergy:
Doxycycline 200mg po on
day 1 then 100mg po od
Human or
animal bite
Mastitis
Penicillin allergy or MRSA
suspected: Vancomycin iv
dosed according to local
guidelines
Co-amoxiclav 1.2g tds
Moderatesevere
cellulitis in
association
with diabetes
or post GI
surgery
Necrotising
Fasciitis
If severe consider adding
Clindamycin 300-450mg
po qds
Penicillin allergy:
Clindamycin 600mg iv qds
& Ciprofloxacin 750mg po
bd (or 400mg iv bd if oral
route not appropriate)
Meropenem 1g tds
& Clindamycin 600mg iv
qds
& Metronidazole 500mg
tds & single dose
Gentamicin 5mg/kg
Flucloxacillin 500mg qds
Total
Duration
7 days
Additional Comments
5 - 7 days
Only if severe consider adding
Clindamycin 300-450mg po
qds to Flucloxacillin /
Vancomycin
(substitute if on Doxycycline)
Check tetanus status and
discuss with Microbiology if
human bite or concern
regarding rabies
7 days
Flucloxacillin 500mg qds
OR
consider Co-amoxiclav
625mg tds if
breastfeeding, post operative or recent
Flucloxacillin
Penicillin allergy or MRSA
suspected:
Discuss with Microbiology
5-7days
Co-amoxiclav 625mg tds
7 -10
days
If MRSA is suspected add
Vancomycin iv dosed
according to local guidelines
Liaise with Diabetic Foot Team
Penicillin allergy:
Discuss with Microbiology
Not appropriate
According
to clinical
response
If suspected get an URGENT
surgical opinion and discuss
with a Microbiologist
If MRSA is suspected add
Vancomycin iv dosed
according to local guidelines
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 13 of 26
Adult Empirical Treatment Guidelines: Skin and Soft Tissue
Infection
Antibiotic Treatment IV
Antibiotic
Total
Additional Comments
Option
Treatment Oral
Duration
Option
Severe pre
Discuss with
According Discuss with Microbiology,
Ceftriaxone 2g bd
Microbiology
septal and
to clinical
Ophthalmology and ENT
orbital cellulitis Penicillin allergy or MRSA Penicillin allergy or
response
Consider urgent imaging
suspected: Discuss with
MRSA suspected:
Microbiology
Discuss with
Microbiology
Cellulitis
Flucloxacillin 1g qds
Flucloxacillin 500mg According Consider possibility of a deep
surrounding
to clinical
+/- Metronidazole 500mg
seated infection and referral to
qds +/ulcer or
response
tds
Tissue Viability
Metronidazole
pressure sore
400mg tds
OR
Co-amoxiclav 625mg
tds
Penicillin allergy or MRSA Penicillin allergy or
suspected: Vancomycin iv MRSA suspected:
dosed according to local
Doxycycline 200mg
guidelines +/on day 1 then 100mg
Metronidazole 500mg tds
od +/- Metronidazole
400mg tds
Ulcer or
Pressure relief and topical wound care should be adequate
pressure sore
with no
evidence of
cellulitis
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Adult Empirical Treatment Guidelines: Gynaecology
Infection
PID (low risk
gonococcal)
PID (high risk
gonococcal)
Antibiotic
Treatment IV
Option
Ceftriaxone
2g od &
Metronidazole
500mg tds &
Doxycycline
100mg po bd
Antibiotic
Treatment Oral
Option
Ofloxacin
400mg bd &
Metronidazole
400mg bd
Ceftriaxone 2g
od &
Metronidazole
500mg tds &
Doxycycline
100mg po bd
IM ceftriaxone
500mg single
dose then
Doxycycline
100mg po bd &
Metronidazole
400mg po bd
Total
Duration
Additional Comments
14 days
Pregnancy: Use Erythromycin instead of
Doxycycline
Refer to GUM
14 days
Anaerobes are of greater importance in severe
PID; Metronidazole may be discontinued in
patients with mild or moderate PID who are
unable to tolerate it.
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 14 of 26
Adult Empirical Treatment Guidelines: Intra-abdominal Infections
Infection
Antibiotic Treatment IV
Antibiotic
Option
Treatment Oral
Option
Amoxicillin 1g tds &
Co-amoxiclav 625mg
Appendicitis,
Metronidazole 500mg tds &
tds & Metronidazole
diverticulitis
Gentamicin 5mg/kg od
400mg tds
OR
or peritonitis
If eGFR <45, treat with
Piperacillin-tazobactam 4.5g
tds & Metronidazole 500mg
iv tds
Penicillin allergy:
Penicillin allergy:
Teicoplanin 600mg 12 hourly Ciprofloxacin 500 mg
for 3 doses then 600mg od & bd & Metronidazole
Metronidazole 500mg tds &
400mg tds
Gentamicin 5mg/kg od
OR
If eGFR <45, discuss with
Microbiology
Amoxicillin 1g tds &
Co-amoxiclav 625mg
Cholecystitis
Metronidazole 500mg tds &
tds & Metronidazole
and
Gentamicin 5mg/kg od
400mg tds
OR
Cholangitis
If eGFR <45, treat with
Piperacillin-tazobactam 4.5g
iv tds & Metronidazole
500mg iv tds
Severe
Pancreatitis
with infected
necrosis
Penicillin allergy:
Teicoplanin 600mg 12 hourly
for 3 doses then 600mg od &
Metronidazole 500mg tds &
Gentamicin 5mg/kg od
OR
If eGFR <45, discuss with
Microbiology
Piperacillin/ tazobactam 4.5g
tds& Metronidazole
500mg iv tds
Total
Duration
Additional Comments
5 - 7 days
Continue IV for 5-7 days if
peritoneal contamination
Review with culture results
prior to switching to oral
therapy
7 days
Penicillin allergy:
Ciprofloxacin 500 mg
bd & Metronidazole
400mg tds
Not appropriate
7 days
Penicillin allergy: Discuss
with Microbiology
Add Gentamicin 5mg/ kg
od if septic
Note:
Infected necrosis is rare in
the first week. Infection is
presumed when there is
extraluminal gas in the
pancreatic and/or
peripancreatic tissues or
when FNA is positive for
bacteria and / or fungi on
Gram stain and culture.
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 15 of 26
Adult Empirical Treatment Guidelines: Intra-abdominal Infections
Infection
Antibiotic Treatment IV
Antibiotic Treatment
Option
Oral Option
Piperacillin/ tazobactam
Spontaneous
4.5g iv tds
Be guided by culture
Bacterial
results
Peritonitis
Penicillin allergy: Discuss
with Microbiology
Variceal
haemorrhage
with cirrhosis
Piperacillin/ tazobactam
4.5g iv tds
Total
Duration
Additional Comments
5-7 days
5-7 days
Penicillin allergy:
Teicoplanin 600mg 12
hourly for 3 doses then
600mg od &
Gentamicin 5mg/kg od
OR
If eGFR <45, discuss with
Microbiology
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly.
“Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 16 of 26
References
British National Formulary 65th edition. March- September 2013.
Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare
Associated Infection (ARHAI). Antimicrobial Stewardship: “Start Smart – Then Focus”.
2011.
Scottish Intercollegiate Guidelines Network. Management of suspected bacterial urinary
tract infection in adults. Clinical Guideline 88. Updated July 2012.
British Society for Sexual Health and HIV. Management of epididymo-orchitis (2010)
http://www.bashh.org/documents/3546.pdf
British Society for Sexual Health and HIV. United Kingdom National guideline for the
management of prostatitis (2008)
IDSA Guidelines. Practice Guidelines for the Management of Bacterial Meningitis. Clin
Infect Dis 2004; 39:1267–84
http://cid.oxfordjournals.org/content/39/9/1267.full
Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of
the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob
Chemother 2012; 67: 269–289.
http://jac.oxfordjournals.org/content/67/2/269.full.pdf+html
British Thoracic Society. Guidelines for the Management of Community Acquired
Pneumonia in Adults. Thorax 2009, Vol 64 Supplement III
http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Pneumonia/CAPGuideline-full.pdf
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and
Adults. Clin Infect Dis. 2012 doi: 10.1093/cid/cir1043
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Repanos C, Mukherjee P, Alwahab Y. Role of microbiological studies in management of
peritonsillar abscess J Laryngol Otol. 2009;123(8):877-9. doi:
10.1017/S0022215108004106. Epub 2008 Dec 4.
.
IDSA Guidelines. Practice Guidelines for the Diagnosis and Management of Group A
Streptococcal Pharyngitis. Clin Infect Dis 2002; 35:113–25.
http://cid.oxfordjournals.org/content/35/2/113.full.pdf+html
SIGN Guideline 117. April 2010. Management of sore throat and indications for
tonsillectomy, A national clinical guideline.
http://www.sign.ac.uk/pdf/sign117.pdf
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 17 of 26
BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen
joint in adults. Rheumatology 2006; 45 (8): 1039-1041.
http://rheumatology.oxfordjournals.org/content/45/8/1039.full.pdf+html
British Society for Sexual Health and HIV. UK National Guideline for the Management of
Pelvic Inflammatory Disease (2011).
http://www.bashh.org/documents/3572.pdf
IDSA Guidelines. Practice Guidelines for the Diagnosis and Management of Skin and
Soft-tissue. Clin Infect Dis. 2005;41:1373-406.
UK Guidelines for the Management of Acute Pancreatitis. Gut 2005;54:iii1-iii9
doi:10.1136/gut.2004.057026
http://gut.bmj.com/content/54/suppl_3/iii1.full
AASLD Practice Guidelines. Prevention and Management of Gastroesophageal
Varices and Variceal Hemorrhage in Cirrhosis. Hepatology 2007; 46 (3).
http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guideli
nes/prevention%20and%20management%20of%20gastro%20varices%20and%20hem
orrhage.pdf
Jalan R and Hayes PC.UK Guidelines on the management of patients with variceal
haemorrhage in cirrhotic patients.
Gut 2000;46:iii1-iii15 doi:10.1136/gut.46.suppl_3.iii1
http://gut.bmj.com/content/46/suppl_3/iii1.full
IDSA Guideline. Diagnosis and Management of Complicated Intra-abdominal Infection
in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious
Diseases Society of America. Clin Infect Dis 2010;50:133-64.
EASL clinical practice guidelines on the management of ascites, spontaneous bacterial
peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology 2010; 53:397417.
http://www.easl.eu/assets/application/files/21e21971bf182e5_file.pdf
Classification of acute pancreatitis—2012: revision of the Atlanta classification and
definitions by international consensus. Banks et al. Gut 2013;62:102–111.
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 18 of 26
Related documents
•
•
•
•
•
•
•
Guidelines for the dosing and monitoring of Gentamicin, Vancomycin and
Teicoplanin
Guidelines for UTI in Elderly
Neutropenic Sepsis Guideline
Antibiotic Guidelines: Paediatric and Neonatal
Control of Infection Strategy
Antibiotic prescribing Policy
Antibiotic Guideline: Surgical Prophylaxis in Adults
List of abbreviations
CAP Community Acquired Pneumonia
CF
Cystic Fibrosis
CSU Catheter sample of urine
ESBL Extended Spectrum Beta-Lactamase
HAP Hospital Acquired Pneumonia
HSV Herpes Simplex Virus
IE
Infective Endocarditis
MRO Multi-resistant organisms
MSU Mid- stream urine
NAAT Nucleic Acid Amplification Test
OPAT Outpatient Parenteral Antibiotic Therapy
PID Pelvic Inflammatory Disease
STI Sexually Transmitted Infection
VRE Vancomycin Resistant Enterococci
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Version: 1.0
Approved on: 2013
Review date: 2016
Page 19 of 26
Appendix 1: Guidance on Penicillin Allergies
Penicillin Containing Antibiotics:
Amoxicillin
Augmentin (Co-amoxiclav contains amoxicillin & clavulanic acid )
Flucloxacillin
Penicillin G (benzylpenicillin)
Penicillin V (phenoxymethyl-penicillin)
Piperacillin + tazobactam (Tazocin)
CONTRA-INDICATED
Cephalosporins:
Crossover allergy possible
(up to 6.5%):
Cefalexin(s)
Cefotaxime(s)
Cefradine(s)
Avoid if history of immediate hypersensitivity to
penicillin. Use with caution if non-severe allergy (e.g.
minor rash only)
Cefaclor(s)
Ceftazidime(s)
Ceftriaxone(s)
Other beta-lactam antibiotics :
Aztreonam(s)
Ertapenem(s)
Cefuroxime(s)
Cefixime(s)
Meropenem(s)
®
Non Beta-lactam antibiotics:
®
Amikacin
(s)
Azithromycin
®
Chloramphenicol
(s)
Ciprofloxacin
(s)
Clarithromycin
(s)
Clindamycin
(s)
Colistin
(s)
Co-trimoxazole
CONSIDERED SAFE
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Version: 1.0
Approved by: William Hubbard, Head of Medicine
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Review date: 2016
Date of Issue: 2013
Page: 20 of 26
© Royal United Hospital Bath NHS Trust
Page 20 of 26
Doxycycline
Erythromycin
Gentamicin
(s)
Levofloxacin
®
Linezolid
Metronidazole
(s)
Minocycline
Nitrofurantoin
Oxytetracycline
Rifampicin
Sodium Fusidate
(s)
Teicoplanin
Trimethoprim
(s)
Tobramycin
(s)
Vancomycin
Appendix 2: Prescribing and monitoring once daily Gentamicin in adults
The standard treatment dose is 5mg/kg,
The standard prophylaxis dose is 3mg/kg
No single dose of Gentamicin should normally exceed 520mg
Neutropenic sepsis dose is 6mg/kg, max dose at discretion of prescribing clinician
Figure 1 Suggested gentamicin doses of 5mg/kg according to height and weight in MALE patients,
taking into account a correction factor for obese patients
Height in feet
Male
6' 5
6' 4
6' 3
6' 2
6' 1
6' 0
5' 11
5' 10
5' 9
5' 8
5' 7
5' 6
5' 5
5' 4
5' 3
5' 2
5' 1
5' 0
280
280
280
280
280
280
280
280
280
280
280
280
280
280
280
280
280
280
60
320
320
320
320
320
320
320
320
320
320
320
320
320
320
280
280
280
280
65
320
320
320
320
320
320
320
320
320
320
320
320
320
320
280
280
280
280
70
360
360
360
360
360
360
360
360
360
360
360
320
320
320
320
280
280
280
75
400
400
400
400
400
400
400
400
360
360
360
320
320
320
320
320
280
280
80
400
400
400
400
400
400
400
400
360
360
360
360
320
320
320
320
320
320
85
440
440
440
440
440
400
400
400
360
360
360
360
360
320
320
320
320
320
90
440
440
440
440
440
400
400
400
400
360
360
360
360
360
360
320
320
320
95
480
440
440
440
440
400
400
400
400
400
360
360
360
360
360
360
320
320
100
480
440
440
440
440
440
400
400
400
400
400
400
360
360
360
360
360
360
105
480
480
440
440
440
440
440
400
400
400
400
400
400
360
360
360
360
360
110
480
480
480
440
440
440
440
440
440
400
400
400
400
400
400
360
360
360
115
480
480
480
480
440
440
440
440
440
440
400
400
400
400
400
400
360
360
120
480
480
480
480
480
480
440
440
440
440
440
440
400
400
400
400
400
400
125
520
520
480
480
480
480
480
440
440
440
440
440
440
400
400
400
400
400
130
520
520
520
480
480
480
480
480
480
440
440
440
440
440
440
400
400
400
135
520
520
520
520
480
480
480
480
480
480
440
440
440
440
440
440
400
400
140
520
520
520
520
520
520
480
480
480
480
480
480
440
440
440
440
440
440
145
520
520
520
520
520
520
520
480
480
480
480
480
480
440
440
440
440
440
150
520
520
520
520
520
520
520
520
520
480
480
480
480
480
480
440
440
440
155
520
520
520
520
520
520
520
520
520
520
480
480
480
480
480
480
440
440
160
520
520
520
520
520
520
520
520
520
520
520
520
480
480
480
480
480
480
165
520
520
520
520
520
520
520
520
520
520
520
520
520
480
480
480
480
480
170
520
520
520
520
520
520
520
520
520
520
520
520
520
520
520
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480
480
175
520
520
520
520
520
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520
520
520
520
520
520
520
520
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520
480
480
180
520
520
520
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520
520
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520
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520
520
520
520
185
520
520
520
520
520
520
520
520
520
520
520
520
520
520
520
520
520
520
190
Actual weight in kg
Figure 2 Suggested gentamicin doses of 5mg/kg according to height and weight in FEMALE
patients, taking into account a correction factor for obese patients
Height in feet
Female
6'
6'
6'
6'
5'
5'
5'
5'
5'
5'
5'
5'
5'
5'
5'
5'
4'
4'
3
2
1
0
11
10
9
8
7
6
5
4
3
2
1
0
11
10
200
200
200
200
200
200
200
200
200
200
200
200
200
200
200
200
200
200
45
240
240
240
240
240
240
240
240
240
240
240
240
240
240
240
240
240
200
50
240
240
240
240
240
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240
240
240
240
240
240
240
240
240
240
240
200
55
280
280
280
280
280
280
280
280
280
280
280
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280
280
240
240
240
240
60
320
320
320
320
320
320
320
320
320
320
280
280
280
280
240
240
240
240
65
320
320
320
320
320
320
320
320
320
320
280
280
280
280
280
240
240
240
70
360
360
360
360
360
360
360
320
320
320
320
280
280
280
280
280
240
240
75
400
400
400
400
360
360
360
320
320
320
320
320
280
280
280
280
280
280
80
400
400
400
400
360
360
360
360
320
320
320
320
320
320
280
280
280
280
85
440
400
400
400
360
360
360
360
360
320
320
320
320
320
320
280
280
280
90
440
400
400
400
400
360
360
360
360
360
360
320
320
320
320
320
280
280
95
440
400
400
400
400
400
360
360
360
360
360
360
320
320
320
320
320
320
100
440
440
400
400
400
400
400
400
360
360
360
360
360
360
320
320
320
320
105
440
440
440
400
400
400
400
400
400
360
360
360
360
360
360
320
320
320
110
440
440
440
440
440
400
400
400
400
400
400
360
360
360
360
360
320
320
115
480
440
440
440
440
440
400
400
400
400
400
400
360
360
360
360
360
360
120
Actual weight in kg
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Version: 1.0
Approved by: William Hubbard, Head of Medicine
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Review date: 2016
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Page 21 of 26
480
480
440
440
440
440
440
440
400
400
400
400
400
400
360
360
360
360
125
480
480
480
440
440
440
440
440
440
400
400
400
400
400
400
360
360
360
130
480
480
480
480
480
440
440
440
440
440
440
400
400
400
400
400
360
360
135
520
480
480
480
480
480
440
440
440
440
440
440
400
400
400
400
400
400
140
520
520
480
480
480
480
480
480
440
440
440
440
440
440
400
400
400
400
145
520
520
520
480
480
480
480
480
480
440
440
440
440
440
440
400
400
400
150
520
520
520
520
520
480
480
480
480
480
480
440
440
440
440
440
400
400
155
520
520
520
520
520
520
480
480
480
480
480
480
440
440
440
440
440
440
160
520
520
520
520
520
520
520
520
480
480
480
480
480
480
440
440
440
440
165
Dosing interval and monitoring
Gentamicin is cleared predominantly via the kidneys and the dosage interval needs to
be increased in patients with impaired renal function.
Renal
Function
Suggested
eGFR
2
Dose Time
interval
First assay
time
Do I give next dose
before assay results
available?
24 hours
Check level 24
hours post
dose
In patients <65 years
old, with good urine
output give 2nd dose
without waiting for result
(ml/min/1.73m )
Normal
> 60
In patients >65 years
old, wait for result
before giving 2nd dose
Impaired
30-60
Severe
Impairment
< 30
Dependent
on levels
Check level 24
hours post
dose
Wait for result before
giving any further doses
Discuss with microbiology
•
Take pre dose levels up to one hour before the second dose is given
•
Patients >65 years old, or with abnormal renal function or poor urine output: the pre
dose gentamicin level must be ≤1mg/litre before any further dose is given
•
For patients with normal and stable renal function check pre dose level twice weekly
•
For patients with abnormal renal function, check the pre dose gentamicin level
before each dose
Renal function must be checked regularly. If renal function deteriorates, more frequent
monitoring may be needed, the dosing interval may need to be increased or
discontinuation of therapy may be required. Discuss alternative antibiotics with a
Microbiologist.
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Version: 1.0
Approved by: William Hubbard, Head of Medicine
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Review date: 2016
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Page 22 of 26
Prescribing and Monitoring of Vancomycin
Normal renal function:
Age
(years)
Vancomycin Dose
Dose Frequency
<65
1000mg
12 hourly
65-75
750mg
12 hourly
>75
500mg
12 hourly
Check levels pre dose levels at 3rd or 4th dose and give dose
Assay twice weekly if pre-dose levels <15mg/l and renal function stable
Impaired renal function:
Renal
Impairment
Suggested
eGFR
(ml/min/1.73m2)
Age
(years)
Vancomycin Dose
Dose
Frequency
Mild to moderate
45-60
>75
1000mg
All ages
1000mg
measure
level at 24h
and await the
result before
giving the
next dose
Moderate or
Severe
<45
Pre dose level should be <15mg/l. Consider dose reduction (e.g. to 750mg OD) if higher
Renal function must be checked regularly. If renal function deteriorates more frequent
monitoring may be needed.
Aim for pre-dose levels 5-15mg/l (aim for 10-15mg/l for serious or deep seated
infections)
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Version: 1.0
Approved by: William Hubbard, Head of Medicine
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Review date: 2016
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Page 23 of 26
Document Control Information
Consultation Schedule
Name and Title of Individual
Dr Paul Lyons, Consultant Neurologist
Dr Dominic Williamson, Consultant in Emergency Medicine
Dr Philip Kaye, Consultant in Emergency Medicine
Dr Chris Dyer, Consultant Geriatrician
Dr Arnold Fernandes, Consultant in GU Medicine
Dr Kate Horn, Consultant in GU Medicine
Dr Anu Garg, Consultant Physician
Dr Mark Mallet, Consultant Physician
Dr John Linehan, Consultant Gastroenterologist
Dr Ben Colleypriest, Consultant Gastroenterologist
Dr Mark Farrant, Consultant Gastroenterologist
Dr Julia Maltby, Consultant Gastroenterologist
Dr Jonathan Quinlan, Consultant Gastroenterologist
Dr Rob Lowe, Consultant Cardiologist
Dr Jacob Easaw, Consultant Cardiologist
Dr Vidan Masani, Consultant Respiratory Physician
Dr Adam Malin, Consultant Respiratory Physician
Dr Tony Robinson, Consultant Physician
Dr Marc Atkin, Consultant Physician
Dr Kim Gupta, Consultant Anaesthetist
Dr Andy Georgio, Consultant Anaesthetist
Mr Simon Gregg-Smith, Consultant Orthopaedic Surgeon
Mr Steve Pope, Consultant Orthopaedic Surgeon
Mr John Budd, Consultant Surgeon
Mr Stephen Dalton, Consultant Colorectal Surgeon
Mr Mike Williamson, Consultant Colorectal Surgeon
Ms Catherine Ashworth, Clinical Director ENT
Mr David Walker, Consultant Gynaecologist
Mr Jon McFarlane, Consultant Urologist
Mr Richard Antcliff, Consultant Ophthalmic Surgeon
Date
Consulted
12/9/13
12/9/13
12/9/13
12/9/13
2/8/13
2/8/13
12/9/13
12/9/13
12/9/13
25/9/13
25/9/13
25/9/13
25/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
12/9/13
The following people have submitted responses to the consultation process:
Name and Title of Individual
Date
Responded
Miss Nicola Lawrence, Consultant Breast Surgeon
20/9/13
Mr Richard Sutton, Consultant Breast Surgeon
18/9/13
Mr Nick Johnson, Consultant Gynaecologist
16/9/13
Mr Rick Porter, Consultant Gynaecologist
18/9/13
Mr David Walker, Consultant Gynaecologist
17/9/13
Mr Mike Williamson, Consultant Colorectal Surgeon
18/9/13
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Version: 1.0
Approved by: William Hubbard, Head of Medicine
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Review date: 2016
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Page 24 of 26
Mr John Budd, Consultant Surgeon
Dr Philip Kaye, Consultant in Emergency Medicine
Miss Claire Taylor, Consultant in Emergency Medicine
Dr Mark Mallet, Consultant Physician
Dr Adam Malin, Consultant Respiratory Physician
Dr Rob Lowe, Consultant Cardiologist
Dr Jacob Easaw, Consultant Cardiologist
Dr Vidan Masani, Consultant Respiratory Physician
Dr Kate Horn, Consultant in GU Medicine
Dr Arnold Fernandes, Consultant in GU Medicine
Mr Neil Bradbury, Consultant Orthopaedic Surgeon
Mr Steve Pope, Consultant Orthopaedic Surgeon
Mr Allister Trezies, Consultant Orthopaedic Surgeon
Name of Committee/s (if applicable)
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Version: 1.0
Approved by: William Hubbard, Head of Medicine
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Review date: 2016
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Page 25 of 26
12/9/13
18/9/13
17/9/13
13/9/13
16/9/13
12/9/13
12/9/13
12/9/13
2/8/13
2/8/13
17/9/13
18/9/13
7/10/13
Date of
Committee
Ratification Assurance Statement
Dear
Please review the following information to support the ratification of the below named
document.
Name of Guideline:
Guideline for the Empirical Treatment of Infections
Name of author:
Wendy Fletcher and Teh Li Chin
Job Title:
Antimicrobial Pharmacist and Consultant Microbiologist
I, the above named author, confirm that:
•
The Guideline presented for ratification describes best practise known to me at the time
of the development of the guideline.
•
I will bring to the attention of my clinical director or line manger any information which
may affect the validity of this Guideline as soon as this becomes known to me;
•
I have undertaken appropriate consultation on this Guideline and have considered all
responses.
•
I acknowledge that the policy will be kept under review, and that I may be asked to refine
the guideline. If no interim changes are required it will then be formally reviewed on its
documented review date.
Signature of Author:
Name of Person
Ratifying this Guideline:
William Hubbard
Job Title:
Head of Medicine
Signature:
Date:
21/11/2013
Date:
21/11/2013
To the person approving this Guideline:
Please ensure this page has been completed correctly, then print, sign and
post this page only to: The Policy Coordinator, John Apley Building.
The whole guideline must be sent electronically to: [email protected]
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Version: 1.0
Approved by: William Hubbard, Head of Medicine
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher
Review date: 2016
Date of Issue: 2013
© Royal United Hospital Bath NHS Trust
Page 26 of 26