1. health and fitness
2. disease

1
Written by: Antimicrobial Management Group
Approved by: Medicines Management Group
Review date: October 2015
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
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Contents
Introduction ..................................................................................................................... 7
Useful contacts ................................................................................................................. 7
General Principles ............................................................................................................ 8
Specimen collection.......................................................................................................... 8
Choice of antibiotic........................................................................................................... 8
Antibiotic prophylaxis....................................................................................................... 9
Route and duration of administration ............................................................................... 9
IV to oral antibiotic switch policy for clinical pharmacists .......................................................... 9
Antibiotic stop/review date and indication policy ....................................................................10
Dose................................................................................................................................11
Poor response .................................................................................................................11
Microbiological reporting ................................................................................................11
Antibiotic assays..............................................................................................................11
Writing prescriptions for antimicrobials ...........................................................................11
Restricted Antimicrobials.................................................................................................12
Management of Clostridium difficile infection ..................................................................14
Preventative measures ....................................................................................................14
Treatment measures .......................................................................................................15
Clostridium difficile Treatment Algorithm ........................................................................16
MRSA Decolonisation Regime ..........................................................................................17
Treatment of Common Infections ....................................................................................18
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Respiratory Tract Infections .............................................................................................18
Upper respiratory tract infections ....................................................................................20
CHRONIC MASTOIDITIS ...........................................................................................................20
INFECTIVE OTITIS EXTERNA .....................................................................................................20
MALIGNANT OTITIS EXTERNA ..................................................................................................21
ACUTE OTITIS MEDIA ..............................................................................................................21
CHRONIC OTITIS MEDIA ..........................................................................................................22
PERITONSILLAR ABSCESS (QUINSY) ..........................................................................................22
TONSILLITIS (EXUDATIVE PHARYNGITIS) ..................................................................................23
ACUTE SINUSITIS .....................................................................................................................24
CHRONIC SINUSITIS .................................................................................................................24
EPIGLOTITTIS ..........................................................................................................................25
WHOOPING COUGH ................................................................................................................25
Lower respiratory tract infections ....................................................................................26
CHRONIC BRONCHITIS & ACUTE INFECTIVE EXACERBATIONS OF COPD .....................................26
BRONCHIECTASIS ....................................................................................................................26
CHEST INFECTION....................................................................................................................27
COMMUNITY ACQUIRED PNEUMONIA (CAP) ...........................................................................29
Table 2: Empirical antibiotic therapy in CAP .............................................................................37
Table 3: Recommended antibiotic choices after pathogen identification...................................39
HOSPITAL ACQUIRED PNEUMONIA – Early Onset .....................................................................42
HOSPITAL ACQUIRED PNEUMONIA – Late Onset ......................................................................43
ASPIRATION PNEUMONIA .......................................................................................................44
NEUTROPENIA-ASSOCIATED PNEUMONIA ...............................................................................45
EMPYEMA ..............................................................................................................................46
TUBERCULOSIS........................................................................................................................46
PNEUMOCYSTIS JIROVECI PNEUMONIA (PJP/PCP) ...................................................................47
Urinary Tract Infections ...................................................................................................48
LOWER URINARY TRACT INFECTIONS .......................................................................................48
LOWER URINARY TRACT INFECTIONS IN PREGNANCY...............................................................49
RENAL TUBERCULOSIS .............................................................................................................50
PROSTATITIS ...........................................................................................................................50
PYELONEPHRITIS/UROSEPSIS ..................................................................................................51
Gastro-intestinal Infections .............................................................................................52
DIARRHOEA (GASTROENTERITIS) .............................................................................................52
DIARRHOEA IN TRAVELLERS RETURNING FROM ABROAD .........................................................52
PERITONITIS/DIVERTICULITIS ..................................................................................................53
CHOLECYSTITIS........................................................................................................................54
PEPTIC ULCER..........................................................................................................................55
SPONTANEOUS BACTERIAL PERITONITIS (SBP) .........................................................................56
DECOMPENSATED LIVER FAILURE ............................................................................................57
BLEEDING VARICES..................................................................................................................57
NECROTISING PANCREATITIS ...................................................................................................58
LIVER ABSCESS ........................................................................................................................58
CAPD PERITONITIS ..................................................................................................................59
FISTULATING/PERIANAL DISEASE ............................................................................................59
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Central Nervous System Infections ..................................................................................60
Meningitis ..............................................................................................................................60
MENINGITIS – AETIOLOGY UNKNOWN.....................................................................................60
BACTERIAL MENINGITIS (LISTERIA) ..........................................................................................61
BACTERIAL MENINGITIS (POST-OPERATIVE OR POST-TRAUMA) ................................................61
BRAIN ABSCESS .......................................................................................................................62
VIRAL ENCEPHALITIS ...............................................................................................................62
Septicaemia.....................................................................................................................63
SEPTICAEMIA (UNKNOWN ORIGIN) .........................................................................................64
NEUTROPENIC SEPSIS ..............................................................................................................65
SEPTICAEMIA (in patient with intravascular catheter) ..............................................................66
Endocarditis ....................................................................................................................67
NATIVE VALVE ENDOCARDITIS (INDOLENT PRESENTATION) .....................................................69
NATIVE VALVE ENDOCARDITIS & SEVERE SEPSIS ......................................................................70
PROSTHETIC VALVE ENDOCARDITIS .........................................................................................71
Skin and soft tissue infections ..........................................................................................72
IMPETIGO ...............................................................................................................................75
CELLULITIS (Localised) .............................................................................................................75
CELLULITIS (Severe, spreading) ................................................................................................76
BOILS ......................................................................................................................................77
DIABETIC FOOT ULCERS ...........................................................................................................77
NECROTISING FASCIITIS ...........................................................................................................78
SURGICAL WOUND INFECTION (GI Surgery) .............................................................................79
SURGICAL WOUND INFECTION (At any other site) ....................................................................80
FUNGAL INFECTION (Dermatophytes) ......................................................................................80
BITES (Human & animal) .........................................................................................................81
Bone and Joint Infections ................................................................................................82
BONE AND JOINT INFECTIONS .................................................................................................82
Viral Infections ................................................................................................................83
CHICKEN POX ..........................................................................................................................83
SHINGLES ................................................................................................................................83
Ophthalmic Infections .....................................................................................................84
CONJUNCTIVITIS (Common purulent) ......................................................................................84
CONJUNCTIVITIS (Chlamydial) .................................................................................................84
CONJUNCTIVITIS (Post-traumatic)............................................................................................85
KERATITIS ...............................................................................................................................85
ENDOPHTHALMITIS (OPHTHALMIC EMERGENCY) .....................................................................86
PRE-SEPTAL CELLULITIS ...........................................................................................................86
ORBITAL CELLULITIS ................................................................................................................87
Genitourinary and Sexually Transmitted Infections ..........................................................88
TRICHOMONIASIS ...................................................................................................................88
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GONORRHOEA ........................................................................................................................88
CHLAMYDIA ............................................................................................................................89
PELVIC INFLAMMATORY DISEASE ............................................................................................89
BACTERIAL VAGINOSIS ............................................................................................................90
VAGINAL CANDIASIS (THRUSH)................................................................................................90
EPIDIDYMO-ORCHITIS .............................................................................................................91
GENITAL HERPES .....................................................................................................................92
SYPHILIS .................................................................................................................................93
GENITAL WARTS .....................................................................................................................93
Dental/Oral Infections .....................................................................................................94
ACUTE ABSCESS ......................................................................................................................94
ACUTE NECROTISING ULCERATIVE GINGIVITIS/PERIODONTITIS ................................................94
AGGRESSIVE PERIODONTITIS ...................................................................................................95
ORO-ANTRAL FISTULA .............................................................................................................96
ORAL CANDIASIS .....................................................................................................................96
OROPHARYNGEAL CANDIASIS .................................................................................................97
ANGULAR CHEILITIS ................................................................................................................97
HERPES SIMPLEX INFECTIONS ..................................................................................................98
Antibiotic Prophylaxis......................................................................................................99
GENERAL SURGERY .................................................................................................................99
VASCULAR SURGERY ...............................................................................................................99
BREAST SURGERY .................................................................................................................. 100
UROLOGICAL SURGERY ......................................................................................................... 101
RENAL SURGERY ................................................................................................................... 101
ENT SURGERY ....................................................................................................................... 101
ORTHOPAEDIC SURGERY ....................................................................................................... 102
ERCP ..................................................................................................................................... 103
SBP (SPONTANEOUS BACTERIAL PERITONITIS) PROPHYLAXIS ................................................. 103
CATHETERISATION ................................................................................................................ 103
ENDOCARDITIS PROPHYLAXIS ............................................................................................... 104
SPLENECTOMY ...................................................................................................................... 105
MENINGITIS .......................................................................................................................... 106
Appendix 1 .................................................................................................................... 107
Once Daily Gentamicin Dosing Protocol ................................................................................. 107
Appendix 2 .................................................................................................................... 110
Guideline for Teicoplanin Dosing in Adults ............................................................................. 110
Appendix 3 .................................................................................................................... 114
Antimicrobial Stop / Review Date and Indication Policy ......................................................... 114
Appendix 4 .................................................................................................................... 124
Antimicrobial IV to PO Switch Policy for Clinical Pharmacists.................................................. 124
Appendix 5 .................................................................................................................... 130
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Guidelines for the Management of Bone & Joint Infections .................................................... 130
Appendix 6 .................................................................................................................... 162
INITIAL MANAGEMENT OF SEPSIS.......................................................................................... 162
Appendix 7 .................................................................................................................... 164
Penicillin Allergy ................................................................................................................... 164
Appendix 8 .................................................................................................................... 165
Guidelines for Antibiotic prophylaxis in relation to urinary bladder catheterisation ................ 165
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These guidelines have been produced by the Antibiotic Management Group, a sub-group of the
Medicines Management Group for the Trust.
It is intended that the information contained in this section be used to guide medical staff on the
most appropriate choice and use of antimicrobial, to provide best patient outcomes and reduce the
risk of adverse events.
Adherence to the guidelines promotes the cost-effective use of antimicrobials and should help to
reduce or stabilise resistance.
Useful contacts
PHARMACY
Ward Pharmacist
Antimicrobial Pharmacists
Medicines information
Out of hours
Via bleep number
Anne Neary Bleep 4502
Kate Vaudrey Bleep 4980
Ext 2096
On-call Pharmacist via duty manager
MEDICAL MICROBIOLOGY
Medical Microbiologist
Out of hours
Ext 4410
On-call Medical Microbiologist via
switchboard
INFECTIOUS DISEASES
ID Registrar on-call
Via switchboard (daytime bleep 4578)
Consultants:
Dr Mike Beadsworth
Dr Nick Beeching
Dr Alastair Miller
Dr Emmanuel Nsutebu
Out of hours
Secretary: 3833/3834
On-call Infectious Diseases Registrar via
switchboard
MEDICAL VIROLOGY
Medical Virologist
Out of hours
Ext 4404
On-call Medical Virologist via switchboard
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Specimen collection
Samples for bacterial culture should preferably be taken before instituting antibiotic therapy as one
or two doses of an antibiotic may prevent the isolation of an infecting pathogen. Situations where
antibiotics should be given immediately are:
Life threatening infections e.g. meningococcal meningitis.
Situations where investigations cannot be done quickly e.g. tuberculosis.
If a patient is already receiving antimicrobial therapy and bacteriological investigation is warranted,
consider suspending therapy (the patient's clinical condition permitting) for 48 - 72 hours before
taking samples and restarting on a different regimen. If the patient is already receiving antibiotics,
please indicate this on the request form.
Samples should be taken from, or as close as possible to, the anatomical focus of the infection. Some
organisms will not survive in or on adjacent tissues (e.g. gonococcus is rarely isolated from high
vaginal swabs even when the infection is obvious on a cervical swab).
In addition, colonising bacterial flora may be construed as having a pathogenic role if the infected
site is not sampled directly (e.g. overgrowth of potential pathogens often occurs on the surface of
infected wounds, ulcers or discharging sinuses but they are seldom responsible for underlying
infection).
Examine the sample before forwarding it to the laboratory to check if it is a good one or not (e.g. a
rectal swab without faecal staining, or a `sputum' sample that is simply frothy saliva are considered
worthless).
Preserve the quality of the sample by putting it in the correct leak proof container or transport
medium and ensuring that it reaches the laboratory within a reasonable time.
Please explain to patients what the microbiological specimen sample is for and how it might affect
their management. Clear and simple instructions and explanations may encourage their active
participation, which may be crucial to obtaining a good quality sample. This applies particularly to
urine collection but also to faeces and sputum.
Choice of antibiotic
The following policy recommends antibiotics for initial treatment and prophylaxis of infections. The
choice of drug is based on local sensitivity and prescribing patterns and has been made after
consideration of clinical efficacy, toxicity, cost and prevention of emergence of resistant strains.
Alternative agents have been suggested for those patients for whom the first choice antibiotic is
inappropriate e.g. in Penicillin allergy.
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Is the patient penicillin allergic? Individuals with a history of anaphylaxis, urticaria or rash
immediately after penicillin administration are at risk of immediate hypersensitivity to a penicillin;
these individuals should not receive a penicillin, a cephalosporin or any other beta-lactam antibiotic.
See appendix 8 for more details on use of antibiotics in penicillin allergy. Please discuss alternative
therapy with Pharmacy or Medical Microbiology/ Infectious Diseases.
Antibiotic prophylaxis
Clinical studies have shown that continuing chemo-prophylaxis beyond the peri-operative period is
no more effective than a single dose or a short course regimen (up to 3 doses). Prolonged
prophylaxis may be detrimental to the patient in that it increases the risk of adverse reactions,
bacterial resistance, and super-infection and increases cost.
Route and duration of administration
If the infection is severe then the intravenous route should be used initially. If the patient is able to
swallow and the antibiotic is well absorbed from the gastro - intestinal tract (e.g. metronidazole,
ciprofloxacin) then the IV route may not be indicated at all. Only if there is a poor response should
the IV route be continued for longer than 48 hours.
IV to oral antibiotic switch policy for clinical pharmacists
By authorising clinical pharmacists to alter antibiotic prescriptions for patients on their own wards,
this policy aims to decrease hospital stay, patient discomfort and overall cost of therapy without
compromising clinical efficacy
Appropriately trained pharmacists will be authorised to alter antibiotic prescriptions on their own
wards with the agreement of a doctor. Oral antibiotics will be used where appropriate and
unnecessarily long courses of antibiotics will be limited.
Patients receiving IV antibiotic therapy will be assessed for a switch to oral therapy using the
inclusion and exclusion criteria. The Pharmacist must then contact a medically qualified member of
the appropriate consultant’s team to discuss the case and suggest a suitable oral antibiotic
alternative.
If the doctor agrees that the pharmacist's suggestions are appropriate the doctor should rewrite the
prescription accordingly. If the doctor agrees to the changes but is not available to change the
prescription the pharmacist will be authorised to rewrite the prescription; this includes adding a new
drug, dose and route of administration, adding finish dates for antibiotic courses and blanking
administration boxes to ensure that unnecessary doses are not given as appropriate. The authorising
doctor must countersign the prescription at the earliest opportunity.
The pharmacist must document any changes they have made in the patient's medical case notes,
along with the name and pager number of the doctor they discussed the case with.
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INCLUSION CRITERIA
(patients must satisfy all of these criteria to be suitable for oral treatment)
Documented or suspected infection
Patient is improving on intravenous therapy with a temperatures of <38oC for >48 hours
and no unexplained tachycardia
Patient is able to take oral fluids
Patient has no potential absorption problems
There is a suitable oral antibiotic available
The professional judgement of the pharmacist agrees that it is appropriate
EXCLUSION CRITERIA
(patients are not suitable for oral treatment if they satisfy any of these criteria)
Meningitis, endocarditis, septic arthritis , osteomyelitis, neutropenic or
immunocompromised patients
Nil by mouth patients
Patients at risk of aspiration
Patients with severe nausea, vomiting, diarrhoea, gastro-intestinal obstruction or motility
disorder
Patients having continuous naso-gastric suctioning
Patients at the end of their antibiotic course
Patients with infections where the culture and sensitivity results show that the organisms
are unlikely to be susceptible to oral antibiotics
Patients who have not yet completed the course of intravenous antibiotics specified by
their consultant or registrar on their prescription chart or case notes
Antibiotic stop/review date and indication policy
Correct use of antimicrobial agents requires that prescriptions are reviewed on a regular
basis to ensure that the selected agent is still appropriate, continuation of therapy is still
necessary and the route is still appropriate.
Unnecessarily long and excessive treatment as a result of therapy not being reviewed can
have an impact on:
increased selection of resistant organisms
antibiotic treatment related illnesses e.g. Clostridium difficile Infection
increased risk of adverse effects
increased expenditure
This policy requires all prescribers to document on the medicine chart, the stop date or intended
duration of treatment and the indication every time an antimicrobial is prescribed.
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All clinical staff – Doctors, Nurses and Pharmacists – have a role to play in implementing and
ensuring the success of this policy. Please see Appendix 4 for more details on the roles and
responsibilities of individual medical staff in the implementation of this policy.
Dose
All doses quoted are either standard antibiotic doses or those recommended by the Microbiology
department/Infectious Diseases Unit. They assume the patient has normal renal and hepatic
function. If renal or hepatic function is impaired doses may need to be modified or altered. Dosage
guidance can be found in the BNF or by contacting a microbiologist (or the Infection Consult Team).
Poor response
If there is no response to treatment within 2 or 3 days or the patient deteriorates, specialist advice
should be sought before changing the antibiotic regimen.
Microbiological reporting
The Microbiology Department will report antimicrobial sensitivities of isolated pathogens in
accordance with these guidelines. For some specimens, sensitivities can be reported within 24 hours,
others tests will be available within 48 hours, unless the organism is multi - resistant or slow
growing.
Antibiotic assays
These are available for the following antibiotics to ensure adequate therapeutic levels and to avoid
toxicity:
Gentamicin
Amikacin
Tobramycin
Vancomycin
Teicoplanin (assess clinical efficacy in selected patients)
Discuss with Pharmacy, Medical Microbiology or Infectious Diseases.
Writing prescriptions for antimicrobials
For full guidance on prescribing and prescription writing please refer to the current British National
Formulary (BNF).
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This is a list of all antimicrobials that are restricted to certain prescribers and/or specific treatment
indications. Any use outside of these recommendations will be challenged and may be refused –
prescriptions not adhering to the guidelines will be referred to Medical Microbiology or the Infection
Consult Team for specialist advice/authorisation.
Any antimicrobial not included in this list or the formulary list will NOT be stocked by the Pharmacy.
Use within the Trust will require application to the Royal Liverpool Hospitals NHS Trust, Medicines
Management Group.
ANTIMICROBIAL
AMIKACIN
AMPICILLIN
AMPHOTERICIN
AZTREONAM
CAPREOMYCIN
CASPOFUNGIN
CYCLOSERINE
CEFOTAXIME
CEFTAZIDIME
CIDOFOVIR
CLOFAZIMINE
COLISTIN
(COLISTEMETHATE SODIUM)
CO-TRIMOXAZOLE
DAPSONE
DAPTOMYCIN
ERYTHROMYCIN
FIDAXOMYCIN
FOSCARNET
FLUCYTOSINE
GANCICLOVIR
IMIPENEM/CILASTIN (PRIMAXIN)
ITRACONAZOLE
KETOCONAZOLE
LEVOFLOXACIN
LINEZOLID
AUTHORISED PRESCRIBERS/
INDICATIONS
Medical Microbiology/ Infectious Diseases
None – Amoxicillin used in preference
Medical Microbiology/Haematology /Infectious
Diseases
Medical Microbiology/ Infectious
Diseases/Haematology
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases/
Haematology
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases/
Respiratory
Medical Microbiology/ Infectious
Diseases/Haematology
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases/
Haematology/ Respiratory
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
For pro-kinetic use only
Medical Microbiology/ Infectious Diseases for
the management of Clostridium difficile infection
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious
Diseases/Haematology
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
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MEROPENEM
MICAFUNGIN
MOXIFLOXACIN
NORFLOXACIN
OFLOXACIN
PIVMECILLINAM
POSACONAZOLE
RIFABUTIN
RIFAXIMIN
SODIUM FUSIDATE
SULFADIAZINE
STREPTOMYCIN
TINIDAZOLE
TOBRAMYCIN
VALACICLOVIR
VALGANCICLOVIR
VANCOMYCIN (INTRAVENOUS)
VANCOMYCIN (ORAL)
VORICONAZOLE
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious
Diseases/GUM/ epididymo-orchitis
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious
Diseases/Gastroenterology – pouchitis only
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases/GUM
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases
Medical Microbiology/ Infectious Diseases/
Haematology/ Renal Transplant – CMV
prophylaxis policy
Medical Microbiology/ Infectious Diseases
Confirmed Clostridium difficile infection – must
have infection control review.
Medical Microbiology/ Infectious Diseases
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Diarrhoea is a common side effect of antibiotic administration. Although in most cases its
pathogenesis cannot be conclusively attributed, it is presumed to reflect alterations in colonic flora
in conjunction with effects on gut motility. Clostridium difficile (C. difficile) is thought to cause about
25% of antibiotic-associated diarrhoea overall.
Prevention of C. difficile infection relies on limiting patients’ exposure to the micro-organism and
ensuring they do not become susceptible through disruption of their normal gut flora. Interventions
for the control of C. difficile infection can be divided into infection control measures and antibiotic
prescribing manipulations – these two strategies should be applied together.
The transmission of C. difficile can be patient to patient, via the contaminated hands of healthcare
workers, or via environmental contamination including healthcare equipment. It is therefore
important that the symptomatic patient is promptly isolated and the isolation policy strictly
followed. (See full Trust clinical policy for comprehensive guidance)
A new 2 step test has been introduced which includes testing for the GDH enzyme (which indicates
presence of the organism) as well as for toxin, using an ELISA test, that indicates active toxin
production. This has led to a change in reporting. In summary:
If GDH is negative and toxin ELISA is negative it is negative.
If GDH is positive and toxin ELISA is positive it is positive.
If GDH is positive and toxin ELISA is negative then C. difficile associated diarrhoea cannot be
excluded and requires assessment.
The following points are intended to help reduce the incidence of C.difficile associated diarrhoea:-
Preventative measures
Rationalise the use of antibiotics.
Review antibiotic prescriptions daily and discontinue as soon as clinically indicated.
Record the date antibiotics were started when rewriting prescription charts.
Medical staff should sign all laboratory reports.
Avoid patient movement between wards for patients with a history of diarrhoea.
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Treatment measures
Take an accurate medicines history from patients with diarrhoea.
Send stool sample for C. difficile at the first opportunity.
Avoid the use of loperamide and other anti - motility agents.
Prescribe Resource Optifibre 1 sachet daily in all clinical/proven cases.
Stop proton pump inhibitors unless absolutely essential.
Ensure Infectious Diseases and Infection Control are consulted.
For each laboratory report, make a case note entry and note treatment instituted.
Stop causative antibiotic if possible
Provide patients with information leaflet relating to C. difficile infection.
Barrier nurse C. difficile positive patients.
Ensure strict personal hygiene measures are observed by staff and patients e.g. hand
washing with soap and water (not alcohol hand rub, which is ineffective for C. difficile)
C. difficile positive patients should have their own toilet facilities which should be cleaned
regularly.
Regularly assess severity of the infection using the severity scoring tool and treat accordingly
MILD
MODERATE
SEVERE*
<3 / day
3-5 / day
>5 / day
Blood WBC
Not raised
< 15
≥ 15
Faecal leucocytes
- / scanty
+
++ / +++
Bowels open
* Clinical markers which should raise suspicion of potentially severe C. difficile infection
include ~ thirst, pyrexia, falling urine output, hypokalaemia, serum creatinine rising to >50%
above baseline, MEWS ≥ 3, elevated blood lactate, and abdominal pain &/or distension.
For severe / potentially severe cases, seek expert advice (Infectious Diseases, Medical Microbiology,
Surgery), particularly regarding the need for imaging (CT abdo is the most sensitive modality for
assessing colitis; PAXR will confirm end-stage toxic megacolon, which may be associated with
paradoxical decrease in frequency of bowel motions).
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Clostridium difficile Treatment Algorithm
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MRSA Decolonisation Regime
Contact Infection Prevention and Control Team for advice on isolation and decontamination
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Respiratory Tract Infections
There are a range of different respiratory tract infections; all of which require different management
plans. The general diagnostic principles to be followed and treatment choices are explained below:
Laboratory Investigations
A good sputum sample (ideally with the help of a physiotherapist) should be obtained prior to
prescribing an antibiotic if the patient can produce a sample immediately. Repeat sample collection
if food particles are visible or saliva only is obtained.
Patients with pneumonia should have blood cultures taken, along with serum, nose/throat swab in
viral transport medium (VTM) and urine for Mycoplasma, Legionella, Chlamydia and Coxiella testing
if clinically indicated.
If TB is suspected, this should be indicated clearly on the request form and the Infection Prevention
and Control Team (IPCT) should be informed. Infectious Diseases and chest physicians should be
involved.
A diagnostic tap should be attempted where there is an associated pleural effusion, as even a small
amount of pleural fluid for microscopy, culture and detection of pneumococcal antigen will increase the
diagnostic yield. Plasma and urine can be tested for pneumococcal antigen. Urinary pneumococcal and
legionella antigen testing will be performed on ill patients after discussion with medical microbiology.
Decision to prescribe and choice of antibiotic
Antibiotics other than those recommended should not usually be prescribed empirically. In
particular, ciprofloxacin or cefradine should not be prescribed unless specifically indicated because
they are not sufficiently broad spectrum to cover common respiratory pathogens.
Antibiotic therapy should be changed when sensitivities are known or following advice from the
microbiologist or respiratory physician.
In order to decide on a course of treatment there are several factors that need to be considered:
Does the patient have a chest infection?
Patients with acute asthma do not routinely need antibiotics unless there is clinical evidence of
infection.
Is the infection community or hospital acquired?
A hospital - acquired infection is generally one that develops after 48 hours in hospital, and may be
due to different organisms.
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Is the patient likely to have an atypical infection?
Symptoms, which lead to a suspicion of pneumonia due to an atypical organism, include headache,
confusion, and diarrhoea.
Signs, which lead to a suspicion of pneumonia due to an atypical organism include rash.
Other features, which lead to suspicion of pneumonia due to an atypical organism, are:
1. X - ray findings that do not correlate with the severity of the illness.
2. Subacute onset with upper respiratory tract infection (Mycoplasma).
3. Pyrexia of unknown origin (PUO) preceding chest symptoms (especially Mycoplasma and
some Legionella).
4. Unproductive cough even after several days illness.
5. Community outbreaks.
6. Exposure to animals (Coxiella and Chlamydia).
7. Residences in hotels or other institutions or exposure to water vapour e.g. jacuzzi
(Legionella).
The chest X - ray appearance is not a good guide to the underlying pathology, especially in the early
stages of the disease. The decision to treat and choice of antibiotic depends upon the overall clinical
picture, particularly indices of severity.
How severe is the infection?
Use BTS CURB-65 score to assess the severity of infection in patients diagnosed with pneumonia
(See treatment of CAP)
Patients presenting with severe community acquired infections or TB, or who have an underlying
chest complaint (e.g. cystic fibrosis, bronchiectasis), or who are immunosuppressed should be
discussed with a medical microbiologist, Infectious diseases physician and/or chest physicians for
specialist advice.
Physiotherapy is an important adjunct to antibiotic therapy in patients with chest infections. All
such patients should be referred to the respiratory physiotherapist for assessment.
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Upper respiratory tract infections
CHRONIC MASTOIDITIS
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Seek advice from ENT surgeons
Comments
INFECTIVE OTITIS EXTERNA
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Otosporin ear drops
Topical to ear
3 drops
TDS-QDS
3 days
Treatment Regimen
Second line
Gentisone HC ear drops
Topical to ear
3 drops TDS
Comments
Note:
1) In the presence of infection do not use steroids
alone. Keep dry.
2) Before using any antimicrobial perform aural toilet.
3 days
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
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MALIGNANT OTITIS EXTERNA
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Piperacillin/Tazobactam
IV
4.5g TDS
Step down to oral therapy*, total
duration 10-14 days.
Treatment Regimen
Second line
Ciprofloxacin AND metronidazole
Oral
Ciprofloxacin 500mg BD
AND
Metronidazole 400mg TDS
10-14 days
Comments
Referral to ENT is advised.
*Step down to oral therapy:
Ciprofloxacin 500mg BD
AND
Metronidazole 400mg TDS
Ciprofloxacin not to be used in epilepsy – discuss
alternative therapy with medical microbiology.
ACUTE OTITIS MEDIA
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Comments
Most cases are viral
Use analgesics/anti-inflammatories only for 3 days – thereafter treat as chronic.
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CHRONIC OTITIS MEDIA
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Streptococcus pneumonia, Haemophilus influenza
Treatment Regimen
First line
Second line
Amoxicillin
Clarithromycin
Oral
Oral
500mg TDS
500mg BD
5 days
5 days
Comments
Referral to ENT is advised.
PERITONSILLAR ABSCESS (QUINSY)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Benzylpenicillin
+/Metronidazole
IV
Benzylpenicillin 1.8g QDS
+/Metronidazole 500mg TDS
3 days then step down to oral
Treatment Regimen
Second line
Clarithromycin
Oral/IV
500mg BD
Comments
Referral to ENT is advised.
Oral step-down to phenoxymethylpenicillin 500mg
QDS for a total of 10 days therapy (including IV
therapy).
10 days
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TONSILLITIS (EXUDATIVE PHARYNGITIS)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Group A β-haemolytic streptococcus (GABHS)
Treatment Regimen
First line
Second line
Phenoxymethylpenicillin
Clarithromycin
Oral
Oral
500mg QDS
500mg BD
10 days
10 days
Comments
Likely to be viral – use CENTOR criteria to assess the
likelihood of bacterial infection:
Tonsillar exudates
Tender anterior cervical lymphadenopathy
Absence of cough
History of fever
The presence of 3 out of the 4 CENTOR criteria has a
positive predictive value of 40-60% for GABHS. If the
patient has 3 or 4 of the CENTOR criteria present, then
treat with antibiotics.
For severe infections, IV therapy may be required
(treat as quinsy).
Third-line (failed) therapy: co-amoxiclav 625mg TDS
for 10 days.
Care - Epstein-Barr virus infection can also present in
this way and is a contra-indication to amoxicillincontaining antibiotics such as co-amoxiclav.
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ACUTE SINUSITIS
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Comments
Most cases are viral
Use analgesics/anti-inflammatories only for 3 days – thereafter treat as chronic.
CHRONIC SINUSITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Streptococcus pneumonia, Haemophilus influenzae, Staphylococcus aureus and anaerobes.
Treatment Regimen
First line
Second line
Co-amoxiclav
Doxycycline
Oral
Oral
625mg TDS
200mg loading dose then 100mg
BD thereafter
5 days
5 days
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
Comments
25
EPIGLOTITTIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Haemophilus influenzae
First line
Ceftriaxone
IV
2g BD
7 days
Treatment Regimen
Second line
Discuss with Medical
Microbiology/Infectious Diseases
Comments
Maintain airway.
WHOOPING COUGH
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
First line
Second line
Discuss with Medical Microbiology/Infectious Diseases
Comments
This is a notifiable condition.
Antibiotics have little effect if administered in the
paroxysmal stage.
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Lower respiratory tract infections
CHRONIC BRONCHITIS & ACUTE INFECTIVE EXACERBATIONS OF COPD
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumonia.
Treatment Regimen
First line
Second line
Comments
Doxycycline
Amoxicillin
Only prescribe antibiotics if two of the following are
present:
Oral
Oral
Increased breathlessness
200mg loading dose then 100mg
500mg TDS
BD thereafter
Increased sputum volume
7 days
7 days
Increased purulence of sputum
3rd line – clarithromycin 500mg BD oral 7 days
BRONCHIECTASIS
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Refer to chest physicians
Send sputum for culture and sensitivity
Treat according to sensitivity patterns of recent isolates
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
Comments
27
CHEST INFECTION
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Amoxicillin
Oral
500mg TDS
7 days
Treatment Regimen
Second line
Clarithromycin
Oral
500mg BD
7 days
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
Comments
28
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
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COMMUNITY ACQUIRED PNEUMONIA (CAP)
The following guidelines have been developed to aid clinicians in the investigation and management
of patients with CAP at the Royal Liverpool University Hospital (RLUH).
Please note that these guidelines do not apply to patients with:
Exacerbations of COPD
Bronchiectasis
Hospital Acquired Pneumonia (HAP)
Aspiration pneumonia
Confirmed or suspected immunocompromised status, such as those patients with HIV
infection, or those receiving immunosuppressive drugs, including high dose systemic
corticosteroids.
When signs of sepsis are evident, the inclusion of Gram-negative cover should be
considered. Patients who are systemically unwell with signs of sepsis should receive a dose
of gentamicin in addition to standard therapy, if the diagnosis of CAP is in any doubt.
Background
The incidence of CAP requiring hospitalisation in the UK varies with age, from 0.3 per 1000/year in
the 18-39 age group to 13 per 1000/year in those >55 yrs. The overall mortality rate is ~ 6-12%, but
>30% in severe CAP. An organism can be identified in research studies in ~ 70% of cases: the
commonest pathogen is Streptococcus pneumoniae. The prevalence of penicillin resistance with
pneumococci in Merseyside is ~4%, only half of which is high level. At the RLUH in 2009-2010, only
0.5% of Streptococcus pneumoniae isolates from sputum were fully resistant to penicillin.
Diagnosis and severity assessment
Patients may be defined as having community-acquired pneumonia if:
They present with at least one symptom of lower respiratory tract infection
and
There are either signs consistent with consolidation or radiological changes consistent with
pneumonia,
and
This has developed in the community or within 48 hours of hospital admission, with no hospital inpatient treatment during the preceding 30 days
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A normal CXR does not automatically exclude a diagnosis of CAP. However, a normal CXR in the
absence of local chest signs makes CAP unlikely.
If the patient has CAP, assess the severity using the CURB-65 score (0-5), which is a prospectively
validated predictor of severity and mortality, but which does not replace clinical judgement. Score 1
for each criterion met:
Confusion- new mental confusion with abbreviated mental test score of 8 or less
Urea >7mmol/l
Respiratory rate ≥30/min
Blood pressure -systolic <90 mm Hg and/or diastolic ≤60mm Hg
65 age ≥65 years
Patients with a score of 0-1 are considered to be mild and can be managed as an outpatient
(mortality <3%).
A score of 2 indicates moderate severity (mortality 9%) and patients should be admitted to hospital.
A score ≥3 indicates severe CAP (mortality >30%) and patients should be assessed for HDU or ITU
(see below).
The CURB-65 score should be interpreted in conjunction with clinical judgment. The following are
additional adverse prognostic features, which may be indicative of greater disease severity than
reflected by the CURB-65 score:
Hypoxemia (SpO2 <92% or PaO2< 8 kPa) regardless of FiO2
Bilateral or multilobar involvement on CXR
White cell count <4 or >20
Presence of significant co-morbidities
Remember to ask about occupation, pets, illicit drugs, sexual and travel history where appropriate
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Investigations
(See table 1)
All patients should have the following investigations on admission:
Blood Tests
FBC
U+Es
Glucose
LFTs
CRP
Chest X-ray
Microbiological Tests (Table 1, Appendix)
Microbiological investigation is not routinely required in cases of mild CAP (CURB-65 score 0 or 1)
a) Sputum should be sent for culture in:
- patients with moderate CAP (CURB-65 score 2) if purulent and patients have not already received
antibiotic therapy
- all cases of severe CAP
- cases where there is a failure to improve on apparently appropriate therapy
Sputum culture for Legionella may be requested when there are specific clinical or epidemiological
grounds for suspicion
b) Blood cultures should be sent in all cases of moderate or high severity (CURB-65 ≥2), before
antibiotic treatment is commenced.
c) Urine should be sent for Legionella and pneumococcal antigen testing in severe cases admitted to
ITU (do not request urine culture and sensitivity). Legionella antigen testing should also be
considered when specific risk factors are identified, or during outbreaks. Requests for antigen testing
not pertaining to ITU patients, should be discussed with a Microbiologist.
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d) Nose/throat swabs in viral transport medium for Mycoplasma pneumoniae and Chlamydia
pneumoniae PCR tests should be considered in patients with:
- severe CAP unresponsive to first antibiotic regimen or
- strong suspicion of “atypical” pathogen on clinical, radiological or epidemiological grounds.
When requesting PCR ensure the date of onset of respiratory symptoms is on the request form.
e) Respiratory virus PCR tests of respiratory tract specimens (nose/throat swabs in viral transport
medium) should be requested during a seasonal epidemic or pandemic of influenza,
f) HIV testing should be offered to all patients with CAP under the age of 70 years. HIV testing should
be considered and offered to patients over the age of 70 on a case by case basis.
g) “Atypical” serology is no longer recommended other than in certain exceptional circumstances.
Such requests should be discussed with a Clinical Microbiologist.
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Table 1: Microbiological investigation of CAP
Summary of recommended microbiological investigations in immunocompetent patients according
to severity.
Severity
Investigations
Comments
CURB-65 score 0-1
No microbiological investigation routinely
recommended
Requests for PCR testing respiratory
pathogens, and urine antigen testing, may be
considered where there is a specific clinical or
epidemiological reason
CURB-65 score ≥2
Blood cultures
recommended
Urinary antigen testing may be arranged if
clinical or epidemiological suspicion
Discuss with Medical Microbiologist (x 4425 or
bl 4415)
Sputum for MC&S
recommended, especially if purulent or no
response to prior antibiotic therapy
Upper respiratory tract sample for
Discuss with Medical Microbiologist (x 4425 or
Mycoplasma/Chlamydophila/ Legionella PCRs bl 4415)
Bronchial washings / Broncho-alveolar lavage Will be tested in full whenever received and
clinical details indicate a diagnosis of CAP
Pleural fluid (when available)
ITU patients
Blood cultures
Urinary antigen testing for Legionella, Strep
pneumoniae
Sputum for MC&S
recommended
Respiratory sample for
Mycoplasma/Chlamydophila/ Legionella PCRs
Bronchial washings / BAL
Pleural fluid (when available)
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Microbiological investigation of patients with community-acquired pneumonia (CAP)
34
Is patient immunocompromised? *
no
Microbiological investigation of CAP in immunocompetent patients
yes
Microbiological investigation of CAP in immunocompromised patients
* Immunocompromised patients - definition
Summary of recommended microbiological investigations in immunocompetent patients according to severity
Notes
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
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Management
Initial Management
Monitor pulse, BP, temperature, mental status, MEWS and SpO2 at least twice daily, and at
least 6-hourly in the severe group (more frequently if required)
Commence Oxygen supplementation to keep PaO2 >8 kPa and SpO2>94-98% (88-92% in
patients known to have COPD and/or retain CO2).
Correct any volume deficit with appropriate crystalloid and /or colloid and monitor
hydration status and urine output carefully. (For weight-based fluid prescribing schedule
refer to separate guideline on the hospital intranet).
Prophylaxis of venous thromboembolism with low molecular weight Heparin should be
considered for all patients who are not fully mobile (and recorded on ICE)
Consider analgesia for pleuritic chest pain
Select an appropriate antibiotic regimen according to Table 2
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Management of severe pneumonia
Consider the possibility of Gram-negative septicaemia, particularly if sepsis is evident and if the diagnosis of CAP is
in doubt. Treatment with IV gentamicin 5mg/kg stat using the calculator (max 450mg) in addition to standard
antibiotic therapy, or treatment for “Sepsis of unknown origin” with piperacillin/tazobactam + gentamicin, is
recommended in such cases.
Patients with severe CAP (CURB-65 ≥3) have a high mortality risk and their management must include:
Administration of first dose of antibiotics intravenously, as soon as possible
Consideration of notification to ITU or CCOT (see below)
Blood cultures
Urgent Pneumococcal and Legionella Antigen testing
Triage to either Respiratory Department (Wards 6X or 6Y) or Infectious Diseases (Wards 3X or 3Y).
** Patients with Severe CAP should not be managed on wards other than Respiratory or Infectious
Diseases wards, unless under exceptional circumstances**
Cases of severe CAP require senior medical review (Consultant or SpR) as soon as possible, and again within 12
hours. Further senior review should continue at least 12 hourly until there is evidence of clinical improvement.
Consider referral for critical care assessment if:
- FiO2 of 60% or greater is required to maintain O2 sats >92%
- multilobar or bilateral lung changes on a chest X-Ray
- serious co-morbidities
- circulatory collapse and/or organ dysfunction secondary to Systemic Inflammatory Response
Syndrome (SIRS)
Treatment escalation: If a patient is failing to respond to first-line treatment, a decision to escalate antibiotic
treatment to IV Tazocin (4.5g TDS) plus IV clarithromycin (500mg BD) can be considered at Consultant or SpR/ST3
or above level. [Please note that Tazocin is a Penicillin: Patients with penicillin allergy who fail to respond to firstline antibiotics should be discussed with Medical Microbiology or Infectious Diseases]
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
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Table 2: Empirical antibiotic therapy in CAP
Record indication, CURB-65 Score & stop date on drug chart
IV gentamicin 5mg/kg stat (max 450mg) using the calculator should be added if the patient is septic
and the diagnosis of CAP is equivocal
Severity
Location of treatment
Antibiotic of choice
Alternative Regime
(Penicillin allergy)
Mild
Home
(i.e. CURB-65
score 0-1)
Mild
(i.e. CURB-65
score 0-1)
Amoxicillin PO 500mg TDS
for 7 days
Hospital (for other reasons Amoxicillin PO 500mg TDS
for 7 days (give IV if unable
e.g. social)
to tolerate oral route)
Moderate
Hospital
(i.e. CURB-65
score 2)
(9% mortality)
Amoxicillin PO 500mg TDS
for 7 days
AND
Clarithromycin PO 500mg
BD for 7 days
(Give IV if unable to tolerate
oral route).
Severe
(i.e. CURB-65
score 3-5; MEWS
≥3 or based on
clinical
judgement)
Hospital and HDU review
if appropriate ( 30%
mortality)
Benzylpenicillin IV 2.4g QDS
AND
Clarithromycin 500mg PO
BD
Treatment duration 7-10
days, with step-down to PO
Amoxicillin 500mg TDS and
Clarithromycin 500mg BD if
no pathogen identified
Clarithromycin PO 500mg BD
for 7 days
Clarithromycin PO 500mg BD
for 7 days (give IV if unable to
tolerate oral route).
Clarithromycin PO 500mg BD
for 7 days (give IV if unable to
tolerate oral route).
OR
Doxycycline PO 200mg loading
dose then 100mg BD
Teicoplanin 1.2g stat then
800mg IV OD
AND
Clarithromycin 500mg PO BD
Discuss with microbiology if in
doubt
Treatment duration 7-10 days
if no pathogen identified
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The antibiotic regimen may be modified when microbiology results become available, as outlined in
Table 3. When no positive cultures have been obtained, treatment is according to the CURB-65
score: 7 days for non-severe and 7-10 days for severe pneumonia (may be extended further
according to clinical judgment).
Drug safety warning: Macrolide antibiotics (such as clarithromycin) are CYP450 inhibitors and may interact
with a number of drugs such as anticonvulsants, statins and warfarin. Please check appendix 1 of the BNF and
discuss with pharmacy for further information. Macrolides should also be used with caution in patients with a
predisposition to QT interval prolongation (e.g. concomitant use of other drugs which prolong QT interval).
Reviewing the antibiotic regimen
All prescriptions for intravenous antibiotic treatment should be reviewed at least every 24 hours.
The following features indicate response to treatment and step down to oral antibiotics can be
considered.
Resolution of fever for > 24 hours
No cardiovascular instability
Clinically hydrated, taking oral fluids and no concerns over absorption
Resolution of tachypnoea and hypoxaemia
Improving white cell count
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
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Table 3: Recommended antibiotic choices after pathogen
identification
Pathogen
Preferred
Alternative
Duration
(days)
S. pneumoniae
Amoxicillin 500 mg-1g TDS PO
Clarithromycin 500 mg BD PO
5-7
or
or
Benzylpenicllin 2.4g QDS IV
Cefuroxime 750 mg –1.5g TDS IV
M. pneumoniae
and
C.pneumoniae
Clarithromycin 500 mg BD PO
Doxycycline 200 mg loading dose
then 100mg BD PO
14
C.psittaci and
C.burnetti
Doxycycline 200mg loading dose
then 100 mg BD PO
Clarithromycin 500 mg BD PO
14
Legionella spp
Fluoroquinolone (PO or IV)
Clarithromycin 500 mg BD PO or IV
14-21
(Consider addition of rifampicin
in severe cases)
(Consider addition of rifampicin in
severe cases)
Amoxicillin 500 mg TDS PO (if
sensitive)
Ceftriaxone 1g OD IV (If severe
penicillin allergy discuss with
Microbiology or ID)
H. influenzae
Gram negative
enteric bacilli
Depends on sensitivity results
7
14-21
Ps. aeruginosa
Piperacillin/Tazobactam 4.5g
TDS IV
Ciprofloxacin 500mg BD PO
14-21
S. aureus (non
MRSA)
Flucloxacillin 1-2g QDS IV +
Rifampicin 600 mg OD or BD PO
Teicoplanin 800 mg OD IV +
Rifampicin 600 mg OD or BD PO
14-21
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Failure to respond to treatment
Patients failing to improve should be reviewed by a senior clinician (preferably Respiratory or
Infectious Diseases).
Review antibiotic dosage, compliance and whether absorption may be impaired.
When patients with severe pneumonia are not improving within 24 hours of the initiation of
appropriate antibiotic therapy, substitution of IV benzylpenicillin with IV piperacillin/tazobactam
should be considered.
Alternative diagnoses, such as pulmonary embolism, pulmonary oedema and underlying malignancy,
should be considered, as should the possibility of sepsis arising from an alternative focus of
infection. Other predisposing conditions might include aspiration, endobronchial obstruction (e.g.
by inhaled foreign body), and bronchiectasis.
The possibility of infection with rarer causative organisms, such as Mycobacterium tuberculosis or
Legionella pneumophila, should be considered, as should the possibility of a previously undiagnosed
immunosuppressive condition. Such patients may need to undergo further investigation, such as
bronchoscopy and lavage.
It may be appropriate to repeat the CXR to look for evidence of complications (e.g. development of
empyema or lung abscess) – see below.
Monitoring for complications
Repeat CRP and CXR and further investigations should be considered, in the light of any new
information after the clinical review.
Parapneumonic effusion – All patients should be referred to Respiratory Medicine for consideration
of pleural ultrasound, thoracocentesis ± insertion of intercostal drain (ICD)
Empyema – Diagnostic aspiration should be arranged, and fluid samples sent separately to
Biochemistry (for pH, LDH and glucose measurement), and Microbiology (for culture & sensitivity
testing). Turbid appearance, pus cells in pleural fluid on Gram stain or pH < 7.2, indicate pleural
infection and necessitate early and effective pleural drainage with an ICD. Pleural fluid should be
sent in a glucose blood bottle (yellow-topped). Please refer to Respiratory Medicine.
Lung abscess – Consider possibility of lung abscess in the event of slow clinical recovery. Raises
possibility of less usual respiratory pathogens, including anaerobes, S. aureus, gram negative enteric
bacilli, and Strep milleri. May also be seen in influenza outbreaks. Consider poor dentition as possible
predisposing factor in these patients.
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Management of community-acquired pneumonia during influenza outbreaks
(See Department of Health guidelines)
A patient with uncomplicated influenza admitted to hospital for other reasons and who has no risk
factors for severe disease does not routinely require antibiotic therapy. The use of antibiotics should
be reviewed daily. Prophylactic or prolonged use of antibiotics for pneumonia may increase the risk
of late superinfection with resistant organisms, which is often associated with rapid deterioration.
Patients with pre-existing co-morbidities (such as chronic lung, heart, renal, liver or neuromuscular
disease and immunosuppression) who are therefore at high risk of severe disease and complications,
and who present with an influenza-like illness, should be strongly considered for antibiotics in
addition to antiviral treatment
Most patients with non-severe influenza-related pneumonia can be treated with oral antibiotics (e.g.
PO doxycycline, co-amoxiclav or clarithromycin for 5-7 days). Antibiotics should ideally be
administered within four hours of admission.
Patients with severe influenza-related pneumonia should be treated promptly with parenteral
antibiotics - IV co-amoxiclav plus clarithromycin is first line; IV Cefuroxime may be used instead of
co-amoxiclav in penicillin-allergic patients. Discuss with Medical Microbiology or Infectious Diseases
if in doubt.
Antiviral treatment of patients with influenza or influenza-like illness is covered by a separate
guideline.
Follow Up
Clinic review should be arranged for all patients at 4 to 6 weeks, and should include a follow-up CXR.
Influenza and pneumococcal vaccination should be considered for patients who have been treated
for CAP, based on current Department of Health guidelines
Smoking cessation advice should be offered to all patients with CAP who are current smokers
References
British Thoracic Society. Guidelines for the management of community acquired pneumonia in
adults: update 2009 Update. Thorax 2009; 64 (Suppl III):iii1-iii55 (available at http://www.britthoracic.org.uk)
Department of Health influenza guidelines (2009) http://www.dh.gov.uk
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HOSPITAL ACQUIRED PNEUMONIA – Early Onset
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Short stay in hospital (early onset<5 days admission)
OR
No recent antibiotic therapy
Streptococcus pneumoniae
Treatment Regimen
First line
Second line
Comments
Co-amoxiclav
Ciprofloxacin
Consolidation on chest x-ray.
IV
PO
Step down to oral as soon as patient improving.
1.2g TDS
500mg BD
7 days
7 days
If penicillin allergic and ciprofloxacin contra-indicated
discuss with Medical Microbiology/Infectious Diseases.
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
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HOSPITAL ACQUIRED PNEUMONIA – Late Onset
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Long stay in hospital (late onset>5 days admission)
OR
Recent antibiotic therapy
Streptococcus pneumoniae, Staphylococcus aureus, Coliforms
Treatment Regimen
First line
Second line
Comments
Piperacillin/Tazobactam
Discuss with Medical
Reduce dose of piperacillin/tazobactam to 4.5g BD if
Microbiology/Infectious Diseases creatinine clearance <20ml/min.
IV
4.5g TDS
If patient colonised or at risk of MRSA add teicoplanin.
7 days
See teicoplanin guidelines (appendix 2) for full dosing
information and advice on monitoring levels. Check
cultures and stop teicoplanin if no evidence of MRSA.
Review with microbiology results and step down to
oral as soon as possible.
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ASPIRATION PNEUMONIA
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus aureus, oral anaerobes, Streptococci.
Treatment Regimen
First line
Second line
Co-amoxiclav
Clarithromycin
AND
Metronidazole
IV
IV
1.2g TDS
Clarithromycin 500mg BD
AND
Metronidazole 500mg TDS
5 days
5 days
Comments
This is not appropriate for aspiration in the absence of
pneumonia i.e. no consolidation on the chest x-ray.
Step down to oral when suitable for oral
administration.
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NEUTROPENIA-ASSOCIATED PNEUMONIA
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus aureus, Pseudomonas aeruginosa, Coliforms.
Treatment Regimen
First line
Second line
Piperacillin/Tazobactam
Meropenem
AND
Gentamicin
IV
IV
Piperacillin/Tazobactam 4.5g TDS
1g TDS
AND
Gentamicin 5mg/kg (max 450mg)
OD
Discuss with Medical
Discuss with Medical
Microbiology/Infectious Diseases
Microbiology/Infectious Diseases
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
Refer to gentamicin calculator and policy (appendix 1)
for full advice on dosing and monitoring.
Seek specialist advice from Medical
Microbiology/Infectious Diseases and Haematology.
If penicillin-allergic please discuss with Medical
Microbiology/Infectious Diseases.
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EMPYEMA
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Piperacillin/Tazobactam
IV
4.5g TDS
Discuss with Medical
Microbiology/Infectious Diseases
Treatment Regimen
Second line
Discuss with Medical
Microbiology/Infectious Diseases
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
Endeavour to drain and isolate infective agent.
TUBERCULOSIS
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Contact Infectious Diseases or chest physician for advice.
Comments
Isolate patient in a side-room until non-infective.
Refer to Trust Guidelines – Isolation of patients with suspected and confirmed TB available on the Intranet.
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PNEUMOCYSTIS JIROVECI PNEUMONIA (PJP/PCP)
Formerly Pneumocystis Carinii Pneumonia
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Co-trimoxazole
IV
120mg/kg/day in 2-4 divided
doses
Discuss with Medical
Microbiology/Infectious Diseases
Treatment Regimen
Second line
Discuss with Medical
Microbiology/Infectious Diseases
Comments
Contact Infectious Diseases or chest physician for
advice.
Consider the volume of fluid required for IV
administration of co-trimoxazole and incorporate this
into the patient’s fluid balance.
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Urinary Tract Infections
LOWER URINARY TRACT INFECTIONS
(Uncomplicated cystitis)
NOTE:
1) In long-term catheterised patients only those with relevant clinical signs of infection need treatment
2) In recurrent prostatitis discuss treatment with Medical Microbiology/Infectious Diseases
3) Short-term urinary catheters must be removed as soon as possible
4) Seek microbiological advice
Pathogen
E. coli, Staphylococcus saprophyticus
Treatment Regimen
First line
Second line
Comments
Antimicrobial
Nitrofurantoin
Cefalexin
The antibacterial efficacy of nitrofurantoin in UTIs
depends on the renal secretion of nitrofurantoin into
Route
Oral
Oral
the urinary tract. In patients with renal impairment,
Dose
50mg QDS
500mg TDS
renal secretion of nitrofurantoin is reduced, which can
Duration of therapy
Females: 3 days
Females: 3 days
result in treatment failure. Nitrofurantoin is therefore
Males: 7 days
Males: 7 days
contraindicated in those with an
eGFR<60ml/min/1.73m2.
Asymptomatic bacteriuria is common in elderly patients
and does not require treatment. Patients aged >65 who
are not septic and who do not have typical urinary
symptoms, should not have a UTI diagnosed on the
basis of a urine dipstick, and should not be treated
empirically. An MSU should be sent to confirm the
diagnosis if UTI is suspected.
If patient is nil by mouth then contact Medical
Microbiology/Infectious Diseases.
If recurrent UTIs, consider referral to urology.
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LOWER URINARY TRACT INFECTIONS IN PREGNANCY
(Uncomplicated cystitis)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
E. coli, Staphylococcus saprophyticus
First line
Cefalexin
Oral
500mg TDS
7 days
Treatment Regimen
Second line
Dependent upon trimester:
1st trimester = nitrofurantoin 50mg
QDS for 7 days
2nd trimester = nitrofurantoin 50mg
QDS for 7 days
Comments
If patient is nil by mouth then contact Medical
Microbiology/Infectious Diseases.
Take an MSU for culture and sensitivity, and change
treatment according to results as pyelonephritis is
relatively common in pregnancy.
3rd trimester = trimethoprim
200mg BD for 7 days
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RENAL TUBERCULOSIS
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Discuss with Medical Microbiology/Infectious Diseases
Comments
Send 3 consecutive early morning specimens of urine
PROSTATITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Elderly - coliforms
First line
Ciprofloxacin
Oral
750mg BD
4 weeks
Treatment Regimen
Second line
Trimethoprim
Oral
200mg BD
4 weeks
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
Comments
51
PYELONEPHRITIS/UROSEPSIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
E.coli, Klebsiella sp., Proteus, coliforms.
First line
Piperacillin/Tazobactam
+/STAT dose of gentamicin if septic
IV
Piperacillin/tazobactam 4.5g TDS
+/Gentamicin 5mg/kg (max 450mg)
STAT
7 days
Treatment Regimen
Second line
Ciprofloxacin
+/STAT dose of gentamicin if septic
PO/IV
Ciprofloxacin 500mg BD
+/Gentamicin 5mg/kg (max 450mg)
STAT
7 days
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
If patient is vomiting an initial dose of ciprofloxacin
400mg IV may be given.
Refer to gentamicin calculator and policy (appendix 1)
for full advice on dosing and monitoring.
Oral step-down to be governed by culture and
sensitivity results.
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Gastro-intestinal Infections
DIARRHOEA (GASTROENTERITIS)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
E.coli, Coliforms, Salmonella sp., Shigella sp., Campylobacter sp., E. coli 0157, Rotavirus, Norovirus
CONSIDER CLOSTRIDIUM DIFFICILE
Treatment Regimen
First line
Second line
Comments
Refrain from prescribing antimicrobial therapy, unless the patient has features to suggest severe sepsis, is frail or
immunosuppressed. Discuss with Medical Microbiology/Infectious Diseases.
DIARRHOEA IN TRAVELLERS RETURNING FROM ABROAD
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Salmonella sp., Giardia, Norovirus, Rotavirus, Shigella sp., Amoeba, E. Coli, Campylobacter sp.
Treatment Regimen
First line
Second line
Comments
Stool sample required. Seek specialist advice from Infectious Diseases.
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PERITONITIS/DIVERTICULITIS
Pathogen
Antimicrobial
Coliforms, anaerobic cocci, Bacteroides sp.
Treatment Regimen
First line
Second line
Piperacillin/Tazobactam
Tigecycline
+/AND
STAT dose of gentamicin if septic
STAT dose of gentamicin
Route
Dose
Step down to oral co-amoxiclav
625mg TDS as soon as possible
for total of 7 days therapy
IV
Piperacillin/Tazobactam 4.5g TDS
+/Gentamicin 5mg/kg (max 450mg)
STAT
Duration of therapy
7 days
Review with microbiology and step
down to oral as soon as possible
IV
Tigecycline 100mg STAT then 50mg
every 12 hours
AND
Gentamicin 5mg/kg (max 450mg)
STAT
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
Refer to gentamicin calculator and policy (appendix 1)
for full advice on dosing and monitoring.
Discuss with Medical Microbiology/Infectious Diseases
if patient not improving.
7 days
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CHOLECYSTITIS
(With or without ascending cholangitis/biliary sepsis)
Pathogen
Antimicrobial
Coliforms, anaerobic cocci, Bacteroides sp.
Treatment Regimen
First line
Second line
Piperacillin/Tazobactam
Tigecycline
+/AND
STAT dose of gentamicin if septic
STAT dose of gentamicin
Route
Dose
Step down to oral co-amoxiclav
625mg TDS as soon as possible
for total of 5 days therapy
IV
Piperacillin/Tazobactam 4.5g TDS
+/Gentamicin 5mg/kg (max 450mg)
STAT
Duration of therapy
7 days
Review with microbiology and step
down to oral as soon as possible
IV
Tigecycline 100mg STAT then 50mg
every 12 hours
AND
Gentamicin 5mg/kg (max 450mg)
STAT
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
Refer to gentamicin calculator and policy (appendix 1)
for full advice on dosing and monitoring.
Discuss with Medical Microbiology/Infectious Diseases
if patient not improving.
7 days
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PEPTIC ULCER
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Helicobacter pylori
First line
Amoxicillin
AND
Clarithromycin
AND
PPI (see comments)
Oral
Amoxicillin 1g BD
AND
Clarithromycin 500mg BD
7 days
Treatment Regimen
Second line
Metronidazole
AND
Clarithromycin
AND
PPI (see comments)
Oral
Metronidazole 400mg BD
AND
Clarithromycin 250mg BD
7 days
Comments
A PPI should be co-administered for 7 days. Choose
from:
1) Omeprazole 20mg BD, or
2) Lansoprazole 30mg BD
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SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Streptococcus pneumoniae, Staphylococcus aureus, Coliforms
Treatment Regimen
First line
Second line
Piperacillin/Tazobactam
Tigecycline
AND
Stat dose of gentamicin
IV
IV
4.5g TDS
Tigecycline 100mg STAT then 50mg
every 12 hours
AND
Gentamicin 5mg/kg (max 450mg)
STAT
5 days
5 days
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
Refer to gentamicin calculator and policy (appendix 1)
for full advice on dosing and monitoring
Contact Medical Microbiology/Infectious Diseases if
not improving.
Review with microbiology results and step down to
oral as soon as possible.
Diagnosis of SBP: Ascitic (fluid) polymorphonuclear
leukocyte (PMN) counts > 250 cells/mm3 (0.25x109/l)
even if gram stain and culture are negative for
organisms.
For prophylaxis of SBP see section on antibiotic
prophylaxis.
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DECOMPENSATED LIVER FAILURE
(Acute on chronic liver failure e.g. Child’s C)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Piperacillin/Tazobactam
IV
4.5g TDS
5 days
Treatment Regimen
Second line
Ciprofloxacin
Oral
500mg BD
5 days
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
Patients presenting with:
Creatinine clearance <50ml/min
Hepato-renal syndrome
Existing Childs C cirrhosis
May on the discretion of the Consultant
Gastroenterologist be prescribed fluconazole 200mg
OD
BLEEDING VARICES
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Piperacillin/Tazobactam
IV
4.5g TDS
5 days
Treatment Regimen
Second line
Ciprofloxacin
Oral
500mg BD
5 days
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
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NECROTISING PANCREATITIS
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Seek specialist advice
Comments
LIVER ABSCESS
Pathogen
Antimicrobial
Route
Dose
Coliforms, Enterococci, Anaerobes, Staphylococcus aureus
Treatment Regimen
First line
Second line
Piperacillin/Tazobactam
Tigecycline
+/AND
STAT dose of gentamicin if septic
Stat dose of gentamicin
IV
Piperacillin/Tazobactam 4.5g TDS
+/Gentamicin 5mg/kg (max 450mg)
STAT
Review with microbiology and step
down to oral as soon as possible
IV
Tigecycline 100mg STAT then 50mg
every 12 hours
AND
Gentamicin 5mg/kg (max 450mg)
STAT
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
Refer to gentamicin calculator and policy (appendix 1)
for full advice on dosing and monitoring
Review with microbiology results and step down to
oral as soon as possible.
Contact Medical Microbiology/Infectious Diseases if
not improving.
Consider amoebic abscess.
Duration of therapy
Review with microbiology results
Review with microbiology results
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CAPD PERITONITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus. epidermidis, Coliforms, Staphylococcus. aureus, Pseudomonas
Treatment Regimen
First line
Second line
Refer to renal team and policy.
Comments
FISTULATING/PERIANAL DISEASE
E.g. acute flare of Crohn’s disease
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Ciprofloxacin
AND
Metronidazole
Treatment Regimen
Second line
Discuss with Medical
Microbiology/Infectious Diseases
and Gastroenterology
Comments
Must only be prescribed on the advice of a Consultant
Gastroenterologist.
Oral
Ciprofloxacin 500mg BD
AND
Metronidazole 400mg TDS
8-12 weeks
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Central Nervous System Infections
Meningitis
NOTE – Unless meningococcal septicaemia is suspected then the patient should have a lumbar puncture (LP) before antibiotics provided the LP can be done
within 30 minutes. If bacterial meningitis is suspected and the LP cannot be done within 30 minutes then antibiotics should be given but the LP done as
soon as possible and definitely within 4 hours of the antibiotic dose.
MENINGITIS – AETIOLOGY UNKNOWN
NOTE: Treatment should not be withheld in suspected cases of bacterial meningitis whilst laboratory specimens are collected.
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Ceftriaxone
IV
2g BD
72 hours then review
Treatment Regimen
Second line
Chloramphenicol
IV
1g QDS
72 hours then review
Comments
If penicillin-resistant Streptococcus pneumoniae is
suspected, or if a patient has recently returned from
areas where this is prevalent (e.g. Spain, South East
Asia, USA) then add:
Vancomycin IV 1g BD AND
Rifampicin (PO or IV) 600mg BD
Discuss vancomycin dosing and monitoring with
Medical Microbiology and Pharmacy.
If age is > 55 or if significantly immunocompromised
then add amoxicillin IV 2g QDS. In penicillin allergy,
use co-trimoxazole IV 1.44g BD.
If viral encephalitis is a significant risk add aciclovir IV
10mg/kg TDS.
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BACTERIAL MENINGITIS (LISTERIA)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Amoxicillin
AND
Gentamicin
IV
Amoxicillin 2g QDS
AND
Gentamicin 160mg BD
14-21 days
Treatment Regimen
Second line
Discuss with Medical
Microbiology/Infectious Diseases
Comments
Discuss duration of therapy with Medical
Microbiology/Infectious Diseases.
Gentamicin dosing should be adjusted according to
levels taken pre 3rd dose.
Target level pre dose < 1mg/L
Gentamicin doses may need to be adjusted in renal
impairment. Further dosing advice may be obtained
from Pharmacy or Medical Microbiology.
BACTERIAL MENINGITIS (POST-OPERATIVE OR POST-TRAUMA)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Haemophilus influenza, Coliforms, Streptococcus pneumonia, Pseudomonas, Staphylcoccus aureus.
Treatment Regimen
First line
Second line
Comments
Seek specialist advice – discuss with The Walton Centre for Neurology and Neurosurgery (WCNN)
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BRAIN ABSCESS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Streptococci, anaerobes.
Treatment Regimen
First line
Second line
Comments
Seek specialist advice – discuss with The Walton Centre for Neurology and Neurosurgery (WCNN)
VIRAL ENCEPHALITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Herpes simplex
First line
Aciclovir
IV
10mg/kg 8 hourly
Discuss with Medical
Virology/Infectious Diseases
Treatment Regimen
Second line
Discuss with Medical
Virology/Infectious Diseases
The Royal Liverpool & Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-2015
Comments
63
Septicaemia
Treatment of bacteraemia/septicaemia is based on probable origin of infection.
Specimens: Blood culture.
It is essential to collect at least one set before starting antibiotics. If clinical circumstances permit, a further 2 sets may be taken, by separate
venepuncture, during a 2-4 hour period.
Duration: In all cases intravenous antibiotics should be given for not less than 2 days and should continue for at least 24 hours after clinical
recovery. If no clinical response after 48 hours, contact Medical Microbiology/Infectious Diseases.
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SEPTICAEMIA (UNKNOWN ORIGIN)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Coliforms, Streptococcus pneumoniae, Staphylococcus aureus, Pseudomonas, Others
Treatment Regimen
First line
Second line
Comments
Piperacillin/Tazobactam
Teicoplanin
Convert IV metronidazole and ciprofloxacin to oral as
AND
AND
soon as possible.
Gentamicin
Metronidazole
AND
Reduce dose of piperacillin/tazobactam to 4.5g BD if
Ciprofloxacin
creatinine clearance <20ml/min.
Consider
Gentamicin STAT
Refer to gentamicin calculator and policy (appendix 1)
for full advice on dosing and monitoring.
IV
IV
Piperacillin/Tazobactam 4.5g TDS
Teicoplanin 1.2g STAT dose then
Use teicoplanin if high risk or colonised with MRSA.
AND
800mg OD thereafter
Gentamicin 5mg/kg (max 450mg)
AND
Refer to teicoplanin guidelines (appendix 2) for full
STAT
Metronidazole
dosing advice and monitoring of levels.
500mg TDS
AND
Ciprofloxacin 400mg BD
Consider
Gentamicin 5mg/kg (max 450mg)
STAT
7 days
7 days
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NEUTROPENIC SEPSIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Piperacillin/Tazobactam
AND
Gentamicin
IV
Piperacillin/Tazobactam 4.5g TDS
AND
Gentamicin 5mg/kg (max 450mg)
STAT and then OD pending
culture results and clinical
progress.
Treatment Regimen
Second line
Meropenem
IV
1g TDS
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
Refer to gentamicin calculator and policy (appendix 1)
for full advice on dosing and monitoring.
If penicillin allergic discuss with Medical
Microbiology/Infectious Diseases.
Refer to Haematology protocol/Discuss with Haematology
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SEPTICAEMIA (in patient with intravascular catheter)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Acute presentation: Gram negative organisms
Indolent presentation: Gram positive organisms
Treatment Regimen
First line
Second line
Comments
Teicoplanin
Teicoplanin
Refer to gentamicin calculator and policy (appendix 1)
AND
AND
for full advice on dosing and monitoring.
Gentamicin
Consider need for line lock*
Refer to teicoplanin guidelines (appendix 2) for full
IV
IV
dosing advice and monitoring of levels.
Teicoplanin 1.2g STAT then
1.2g STAT then 800mg OD
800mg OD
Remove or change line if practical.
AND
Gentamicin 5mg/kg (max 450mg)
*Discuss with Medical Microbiology/Infectious
OD
Diseases.
7 days
7 days
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Endocarditis
Endocarditis guidelines have been updated based on the BSAC guidelines of 2012 (J Antimicrob
Chemother 2012;67:269-289). This guideline only discusses the initial management. It is then
appropriate to have a multidisciplinary approach with cardiology and infection specialist input,
including changing antimicrobials dependent on aetiology.
Table 1. Criteria for consideration and investigation of possible infective endocarditis
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Table 2. Diagnostic criteria for endocarditis. Modified Duke Criteria
(Li et al. Clin Inf Dis 2000;30:633-8.)
Pathological criteria
Major criteria
Minor criteria
Positive histology or
microbiology of pathological
material obtained at autopsy
or cardiac surgery
2 positive Blood Cultures
showing typical organisms
consistent with infective
endocarditis, such as
Streptococcus viridans and the
HACEK group
Predisposing heart disease
Valve tissue, vegetation,
embolic fragments or
intracardiac abscess content
Persistent bacteraemia from 2
Blood Cultures taken > 12 hours
apart or 3 or more positive
Blood Cultures where the
pathogen is less specific, such as
Staphylococcus aureus and
Staphylococcus epidermidis
Fever > 38
Positive serology for Coxiella
burnetti, Bartonella species, or
Chlamydia psittaci
Positive molecular assays for
specific gene targets
Positive echocardiogram
showing oscillating structures,
abscess formation, new valvular
regurgitation or dehiscence of
prosthetic valves.
Immunological phenomena such as
glomerulonephritis, Osler's nodes,
Roth spots, or positive Rheumatoid
factor
Microbiological evidence not fitting
major criteria
Elevated C reactive protein (CRP) or
erythrocyte sedimentation rate
(ESR)
Vascular phenomena such as major
emboli, splenomegaly, clubbing,
splinter haemorrhages, petechiae or
purpura
• Pathological criteria positive OR
• TWO major criteria OR
• ONE major and TWO minor criteria OR
• FIVE minor criteria
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NATIVE VALVE ENDOCARDITIS (INDOLENT PRESENTATION)
NOTE: Ensure multiple blood cultures have been taken and contact Medical Microbiology/Infectious Diseases
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Teicoplanin
AND
Gentamicin
IV
Teicoplanin 1.2g STAT then 800mg
OD
AND
Gentamicin 80mg BD
Refer to Medical Microbiology/Infectious Diseases and Cardiology
First line
Amoxicillin
AND
Gentamicin
IV
Amoxicillin 2g every 4 hours
AND
Gentamicin 80mg BD
Comments
If patient is stable, await blood culture results prior to
commencing antibiotics.
Monitor gentamicin levels pre 3rd dose.
Aim for: Pre (Trough) < 1mg/L
Gentamicin doses may need to be adjusted in renal
impairment. Further dosing advice may be obtained
from Pharmacy or Medical Microbiology/Infectious
Diseases.
Monitor teicoplanin levels.
Aim for: Pre (Trough) > 20mg/L
Refer to teicoplanin guidelines (appendix 2) for full
dosing advice and monitoring of levels.
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NATIVE VALVE ENDOCARDITIS & SEVERE SEPSIS
NOTE: Ensure multiple blood cultures have been taken and contact Medical Microbiology/Infectious Diseases
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
First line
Second line
Teicoplanin
Discuss with Medical
AND
Microbiology/Infectious Diseases
Gentamicin
IV
Teicoplanin 1.2g STAT then
800mg OD
AND
Gentamicin 80mg BD
Refer to Medical Microbiology/Infectious Diseases and Cardiology
Comments
If patient has risk factors for multi-resistant
enterobacteriaceae or pseudomonas (previous
colonisation, central line in situ, diabetes or
immunosuppression) then change to:
Teicoplanin 1.2g STAT and then 800mg OD thereafter
AND
Meropenem 2g every 8 hours
Monitor gentamicin levels pre 3rd dose.
Aim for: Pre (Trough) < 1mg/L
Gentamicin doses may need to be adjusted in renal
impairment. Further dosing advice may be obtained
from Pharmacy or Medical Microbiology/Infectious
Diseases.
Monitor teicoplanin levels.
Aim for: Pre (Trough) > 20mg/L
Refer to teicoplanin guidelines (appendix 2) for full
dosing advice and monitoring of levels.
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PROSTHETIC VALVE ENDOCARDITIS
NOTE: Ensure multiple blood cultures have been taken and contact Medical Microbiology/Infectious Diseases
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
First line
Second line
Teicoplanin
Discuss with Medical
AND
Microbiology/Infectious Diseases
Gentamicin
AND
Rifampicin
IV & PO
Teicoplanin 1.2g STAT then
800mg OD
AND
Gentamicin 80mg BD
AND
Rifampicin 300mg every 12 hours
PO
Refer to Medical Microbiology/Infectious Diseases and Cardiology
Comments
Monitor gentamicin levels pre 3rd dose.
Aim for: Pre (Trough) < 1mg/L
Gentamicin doses may need to be adjusted in renal
impairment. Further dosing advice may be obtained
from Pharmacy or Medical Microbiology/Infectious
Diseases.
Monitor teicoplanin levels.
Aim for: Pre (Trough) > 20mg/L
Refer to teicoplanin guidelines (appendix 2) for full
dosing advice and monitoring of levels.
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Skin and soft tissue infections
Background
-
Key information from the history
Relevant co-morbidities or precipitating factors (peripheral vascular disease, venous ulcers,
lymphoedema, diabetes, immunosuppression, athlete’s foot)
Clinical clues to unusual pathogens (trauma, water contact, physical activities,
animal/insect/human bites)
Risk factors for thromboembolism
Pace of the spread of the infection
Severe pain (think of necrotising fasciitis, especially if rapid progression and assess for signs
of septic shock)
Associated constitutional symptoms
Any antibiotics in primary care
Recent hospitalisation or known MRSA colonisation
Duration of insertion of any associated intravenous device
Key points on examination
Local features of inflammation (i.e. heat, pain, erythema, swelling). Mark the edge of the
cellulitis for future reference
Lymphangitis and regional lymphadenopathy
Any suggestion of abscess formation or underlying osteomyelitis (be especially suspicious of
this in diabetics and IVDUs)
Any unusual blistering or obvious necrosis
Signs of SIRS/sepsis suggesting bacteraemia
Evidence of metastatic infection (especially vertebral osteomyelitis and endocarditis)
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Investigations
FBC, U&Es, LFTs, Glucose, ESR/CRP
Blood cultures
Skin, wound and/or blister aspirate swabs for M, C&S
Consider screening for MRSA if relevant risk factors
USS may be useful to exclude a DVT or if there is a suspicion of abscess formation
Plain X-rays of underlying bone may show periosteal reaction/lifting in established
osteomyelitis or gas formation in necrotising infections.
Management
Assess severity and document using CREST guideline scoring:
Class I
Patients have no systemic toxicity and no uncontrolled co-morbidities and can
usually be managed with oral antimicrobials on an outpatient basis.
Class II
Patients are either systemically ill or systemically well but with a co-morbidity
such as peripheral vascular disease, chronic venous insufficiency or morbid
obesity which may complicate or delay resolution of their infection.
Class III
Patients may have a significant systemic upset such as acute confusion,
tachycardia, tachypnoea and hypotension or may have unstable co-morbidities
that may interfere with a response to therapy or have a limb-threatening
infection due to vascular compromise.
Class IV
Patients have sepsis syndrome or severe life threatening infection such as
necrotising fasciitis.
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First line therapy: IV flucloxacillin 1g QDS + benzylpenicillin 1.8g QDS
If penicillin allergic use teicoplanin (refer to teicoplanin guidelines in appendix 2 for full
dosing advice and monitoring of levels).
IV→ Oral switch will be considered at senior review, and usually not until at least 48 hours
after commencement of therapy.
Resuscitate and monitor appropriately if there are signs of sepsis
If the patient is systemically well, consider holding off antibiotics if osteomyelitis or deep
abscesses are suspected/proven, in order not to compromise a microbiological diagnosis
If you suspect an associated abscess or necrotising fasciitis (see separate guideline)
Prescribe “prophylactic dose” dalteparin (Fragmin®) 5000 units daily subcutaneously. If
there is clinical suspicion of DVT then give “treatment dose” (weight dependent) until
appropriate imaging can be arranged.
If diabetic, maintain tight glucose control, if necessary with a temporary low-dose insulin
infusion.
Prescribe appropriate analgesia.
Immobilisation and elevation of affected limb.
If athlete’s foot is implicated, treat it with topical miconazole & hydrocortisone (Daktacort ®)
If wound ulcerates/breaks down refer to tissue viability nurse for assessment and advice
about topical hygiene.
Reconsider the antibiotic regimen according to clinical progress and any available
sensitivities.
Oral stepdown
It is reasonable to switch to oral flucloxacillin 1g QDS and amoxicillin 500mg TDS, if penicillin
allergic clindamycin 450mg TDS.
Make sure that the patient receives a total of 14 days of antibiotics.
Second line therapy:
If there is clinical deterioration or a failure to improve after 48-72 hours a second line switch
should be considered.
Appropriate antibiotics include - teicoplanin, clindamycin, daptomycin, linezolid, ceftriaxone and
ceftaroline. This should always be discussed with Medical Microbiology/Infectious Diseases and can
be reviewed by the consult service, via ICE referral.
References
Swartz MN. Cellulitis. New Engl J Med 2004;350:904-912
Stevens DL, Bisno AL, Chambers HF et al. Practice Guidelines for the Diagnosis and Management of Skin and
Soft-Tissue Infections (IDSA guidelines). Clin Infect Dis 2005;41:1373-1406.
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IMPETIGO
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus aureus, Streptococcus pyogenes
Treatment Regimen
First line
Second line
Fusidic acid
Flucloxacillin
Topical
Oral
QDS
500mg QDS
7 days
7 days
Comments
Systemic antibiotics only needed if infection is
widespread.
If patient is penicillin allergic use clindamycin 300mg
QDS PO for 7 days.
CELLULITIS (Localised)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus aureus, Streptococcus pyogenes
Treatment Regimen
First line
Second line
Flucloxacillin
Clindamycin
Oral
Oral
500mg QDS
300mg QDS
Discuss with Medical Microbiology/Infectious Diseases
Comments
For emergency patients consider referral for acute
cellulitis pathway (outpatient parenteral therapy)
If patient colonised or at risk of MRSA use teicoplanin.
Discuss with Medical Microbiology/Infectious Diseases
and refer to teicoplanin guidelines (appendix 2) for full
dosing advice and monitoring of levels.
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CELLULITIS (Severe, spreading)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus aureus, Streptococcus pyogenes
Treatment Regimen
First line
Second line
Flucloxacillin
Teicoplanin
AND
Benzylpenicillin
IV
IV
Flucoxacillin 1g QDS
1.2g STAT then 800mg OD
AND
Benzylpenicillin 1.8g QDS
Usually give 14 days therapy in total
Comments
For emergency patients consider referral for acute
cellulitis pathway (outpatient parenteral therapy)
If patient colonised or at risk of MRSA use teicoplanin.
Discuss with Medical Microbiology/Infectious Diseases
and refer to teicoplanin guidelines (appendix 2) for full
dosing advice and monitoring of levels.
IV to oral switch will be considered at senior review, and usually not
until at least 48 hours after commencement of therapy. See below for
suitable oral agents.
Oral stepdown
Flucloxacillin 1g QDS
AND
Amoxicillin 500mg TDS
Clindamycin 450mg TDS
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BOILS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
First line
Second line
Comments
No antibiotic therapy is indicated, unless there are signs of cellulitis (see above) or if the patient is immunocompromised. Discuss
with Medical Microbiology/Infectious Diseases. If boils recur seek advice from Dermatologist.
DIABETIC FOOT ULCERS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Usually mixed with staphylococcus aureus
Treatment Regimen
First line
Second line
See Bone and Joint guidelines (Appendix 6)
Comments
Antibiotics have no place in the management of ulcers. The fundamental pathology of an ulcer is one of local ischemia
therefore any antibiotic in the bloodstream will not reach the ulcer.
Management therefore must be local. Topical antibiotic use is strongly discouraged. Furthermore, the organisms isolated from
swabs of ulcers may represent what is present in the ulcer rather than what is invading nearby tissue. The complications of
ulcers (cellulitis, osteomyelitis, etc.) should be managed as normal but it must be understood that antibiotic treatment is being
given for these reasons NOT for the ulcer. Where there is evidence of infection seek specialist advice from Medical
Microbiology/Infectious Diseases and the medical diabetes team where appropriate.
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NECROTISING FASCIITIS
NOTE: Surgical debridement is mandatory
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Meropenem
AND
Clindamycin
IV
Meropenem 1g TDS
AND
Clindamycin 900mg TDS
Discuss with Medical
Microbiology/Infectious Diseases
Treatment Regimen
Second line
Discuss with Medical
Microbiology/Infectious Diseases
Comments
Arrange urgent senior surgical review & intervention.
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SURGICAL WOUND INFECTION (GI Surgery)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus aureus, Streptococci, Coliforms, Anaerobes
Treatment Regimen
First line
Second line
Piperacillin/tazobactam
Discuss with Medical
Microbiology/Infectious Diseases
IV
4.5g TDS
7 days
Comments
Reduce dose of piperacillin/tazobactam to 4.5g BD if
creatinine clearance <20ml/min.
Consider gentamicin 5mg/kg (max 450mg OD) if
patient showing signs of sepsis and discuss with
Medical Microbiology/Infectious Diseases.
Refer to gentamicin calculator and policy (appendix 1)
for full advice on dosing and monitoring.
Change to co-amoxiclav when oral route available.
Drain pus if present.
If penicillin allergic contact Medical
Microbiology/Infectious Diseases.
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SURGICAL WOUND INFECTION (At any other site)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus aureus
First line
Flucloxacillin
Oral/IV
500mg-1g QDS
7 days
Treatment Regimen
Second line
Teicoplanin
IV
1.2g STAT then
800mg OD
7 days
Comments
Refer to teicoplanin guidelines (appendix 2) for full
dosing advice and monitoring of levels.
Drain pus if present.
FUNGAL INFECTION (Dermatophytes)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Trichophyton , Microsporum, Epidermophyton
Treatment Regimen
First line
Second line
Terbinafine 1% cream
Terbinafine*
Topical
Oral
BD
250mg OD
7 – 14 days
Discuss with Medical
Microbiology/Infectious Diseases
Comments
*For laboratory proven nail or scalp infections.
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BITES (Human & animal)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Streptococci, Staphylococcus aureus, Anaerobes, Pasturella multocida
Treatment Regimen
First line
Second line
Co-amoxiclav
Doxycycline
AND
Metronidazole
Oral
Oral
625mg TDS
Doxycycline 100mg BD
AND
Metronidazole 400mg TDS
Prophylaxis 7 days
Prophylaxis 7 days
Treatment of infected bites 10-14
days
Comments
For severe bites surgical debridement should be
considered and antibiotic treatment given.
Human Bites – Consider risks of blood borne viral
infection e.g. Hepatitis B, C and HIV.
Exotic animal bites or bites sustained overseas:
Consider rabies risk.
Treatment of infected bites 10-14
days
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Bone and Joint Infections
A comprehensive set of guidance on the treatment of Bone and Joint infections has been produced by the Bone and Joint Infection Group (BJIG). This is a
multi-disciplinary forum of orthopaedic surgeons, medical microbiologists, musculoskeletal radiologists, diabetologists and infectious diseases physicians
(see full guidelines – appendix 6)
BONE AND JOINT INFECTIONS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
First line
Second line
Comments
All bone and joint infections should be referred to Orthopaedics and Medical Microbiology/Infectious Diseases for specialist
advice and follow up.
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Viral Infections
CHICKEN POX
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Varicella zoster
First line
Valaciclovir
Oral
1g TDS
7-10 days
Treatment Regimen
Second line
Discuss with Medical Virology or
Infectious diseases
Comments
Start treatment within 24 hours of onset of rash
Seek advice for patients in high risk groups e.g.
steroids, immunocompromised, in pregnancy.
SHINGLES
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Varicella zoster
First line
Valaciclovir
Oral
1g TDS
7 days
Treatment Regimen
Second line
Discuss with Medical Virology or
Infectious diseases
Comments
Start treatment within 72 hours of onset of rash
Start treatment within 1 week for ophthalmic shingles
(discuss with Ophthalmologist).
For shingles in immunocompromised patients use IV
aciclovir & discuss with Medical Virologist.
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Ophthalmic Infections
CONJUNCTIVITIS (Common purulent)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Streptococcus pneumoniae, Staphylococcus aureus, Viral.
Treatment Regimen
First line
Second line
Chloramphenicol 0.5%
Fusidic acid 1% eye gel
Topical (eye drops)
Topical
1 drop every 3 – 4 hours
BD
3 days
3 days
Comments
3rd line: Gentamicin 0.3% eye drops apply 1 drop every
3 – 4 hours for 3 days.
Do not use steroid-containing eye medications. If no
response after 3 days treatment, seek advice from
Ophthalmology.
CONJUNCTIVITIS (Chlamydial)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Chlamydia
First line
Clarithromycin
Oral
500mg BD
10 days
Treatment Regimen
Second line
Discuss with Medical
Microbiology/Infectious Diseases
Comments
Do not commence therapy until after GUM
assessment.
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CONJUNCTIVITIS (Post-traumatic)
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Comments
Seek advice from Ophthalmology before commencing treatment.
KERATITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Streptococcus pneumoniae, Pseudomonas, Staphylococcus aureus, Herpes simplex, Herpes Zoster.
Treatment Regimen
First line
Second line
Comments
Specific therapy essential – seek Ophthalmic advice.
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ENDOPHTHALMITIS (OPHTHALMIC EMERGENCY)
Pathogen
Many bacteria, viruses and fungi
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Comments
Seek URGENT ophthalmic advice BEFORE commencing treatment.
PRE-SEPTAL CELLULITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus aureus, Streptococci, Haemophilus influenzae
Treatment Regimen
First line
Second line
Co-amoxiclav
Discuss with Medical
Microbiology/Ophthalmology
Oral
625mg TDS
7 days
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ORBITAL CELLULITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Staphylococcus aureus, Streptococci, Haemophilus influenzae
Treatment Regimen
First line
Second line
Ceftriaxone
Discuss with Medical Microbiology/
AND
Infectious Diseases
Metronidazole
IV
Ceftriaxone 2g BD
AND
Metronidazole 500mg TDS
Discuss with Medical
Microbiology/Ophthalmology
Comments
Medical emergency – seek urgent advice.
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Genitourinary and Sexually Transmitted Infections
All suspected and confirmed Sexually Transmitted Infections (STIs) should be referred to GUM or discussed with GUM on call (via switchboard) to enable
appropriate investigation, treatment, follow up and partner notification wherever possible.
TRICHOMONIASIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Trichomonas vaginalis
First line
Metronidazole
PO
2g STAT or
400mg BD for 7 days
Treatment Regimen
Second line*
Tinidazole
Clotrimazole
PO
Vaginal Pessary
2g
500mg OD
STAT
3 days
Comments
* Either dosing schedule may be used.
GONORRHOEA
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Comments
REFER TO GUM – Discuss with GUM on call (24 hour availability)
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CHLAMYDIA
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Azithromycin
PO
1g
STAT
Second line
Doxycycline
PO
100mg BD
7 days
Treatment Regimen
Third line
Erythromycin
PO
500mg BD
14 days
Comments
If pregnant/pregnancy risk use erythromycin.
Chlamydia contacts should be referred to GUM.
PELVIC INFLAMMATORY DISEASE
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Refer to GUM/Medical Microbiology
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BACTERIAL VAGINOSIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Metronidazole
Oral
2g STAT
or
400mg BD for 7 days
Treatment Regimen
Second line
Clindamycin
2% cream
Vaginal
1x5g applicatorful
5 – 7 nights
Comments
Bacterial vaginosis is a clinical diagnosis.
Refer to GUM if diagnosis uncertain.
VAGINAL CANDIASIS (THRUSH)
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Candida albicans
First line
Clotrimazole
Vaginal Pessary
500mg
Single dose
at bedtime
Treatment Regimen
Second line
Fluconazole
Oral
150mg
Single dose
Comments
Alternative (third line) regimens:
Econazole (Gyno-pevaryl)150mg pessary PV
for 3 nights
Miconazole 2% intravaginal cream (GynoDaktarin) 5g applicatorful PV for 14 nights or BD
for 7 days
With vulvitis - Clotrimazole 1% Cream can also be
used BD – TDS for symptomatic relief.
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EPIDIDYMO-ORCHITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Neisseria gonorrhoea, Coliforms, Chlamydia trachomatis
Treatment Regimen
First line
Second line
Ceftriaxone
Ofloxacin
AND
Doxycycline
IM Ceftriaxone 500mg stat
Oral
AND
200mg BD
PO Doxycycline 100mg BD
14 days
For 10-14 days
Comments
Discuss with GUM and urology – treatment may differ.
If sexually transmitted infection (STI) suspected refer
to GUM.
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GENITAL HERPES
NOTE: Refer all cases to GUM but if out of hours do NOT delay treatment.
Ensure viral PCR ulcer swab (viral culture medium – red topped bottle) sent in all ulcer cases.
If isolated ulcer – consider other aetiology – Discuss with GUM.
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Aciclovir
Oral
200mg five times a day
Or
400mg TDS
5 days
Treatment Regimen
Second line
Valaciclovir
Oral
500mg BD
5 days
Comments
Diagnosis is made based on clinical appearance and
history.
If urinary retention discuss with GUM on-call and
urology.
If neurological symptoms discuss with GUM/ID.
3rd line – Famciclovir 250mg PO TDS for 5 days
Other measures – bathing in warm saline
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SYPHILIS
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Refer all cases to GUM
Comments
GENITAL WARTS
Pathogen
First line
Antimicrobial
Route
Dose
Duration of therapy
Treatment Regimen
Second line
Refer to GUM
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Dental/Oral Infections
ACUTE ABSCESS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Amoxicillin
Oral
500mg TDS
3-7 days
Treatment Regimen
Second line
Metronidazole
Oral
200mg TDS
3-7 days
Comments
First or second line may be chosen depending on
clinical presentation
Third line - Clarithromycin 250mg BD for 5 days
Doses of antibiotics can be doubled in severe
infections
Combination of antibiotics - seek opinion from senior
clinician.
ACUTE NECROTISING ULCERATIVE GINGIVITIS/PERIODONTITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Metronidazole
Oral
200mg TDS
3 days
Treatment Regimen
Second line
Amoxicillin
Oral
500mg TDS
3 days
Comments
Periodontal therapy will be required after the acute
phase.
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AGGRESSIVE PERIODONTITIS
NOTE: Several antibiotic regimes have been advocated for aggressive periodontitis.
This regime is occasionally indicated in conjunction with thorough root surface debridement.
Only to be used by or in conjunction with a senior member of staff from the Restorative department
Pathogen
Antimicrobial
First line
Doxycycline*
Route
Dose
Oral
200mg STAT
then
100mg OD
Duration of therapy
21 days
Treatment Regimen
Second line
Metronidazole
AND
Amoxicillin
Oral
Metronidazole
200mg TDS
AND
Amoxicillin
500mg TDS)
7-10 days
Comments
*NOT to be used in children and pregnant women
First or second line may be chosen depending on
clinical and radiographic findings of individual case.
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ORO-ANTRAL FISTULA
Pathogen
Antimicrobial
Route
Dose
First line
Amoxicillin
Oral
500mg TDS
Duration of therapy
5 days
Treatment Regimen
Second line
Doxycycline*
Oral
200mg STAT then
100mg OD
5 days
(after STAT dose)
Comments
*NOT to be used in children and pregnant women
ORAL CANDIASIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Candida albicans
First line
Nystatin suspension
Oral
1ml QDS
7 days
Treatment Regimen
Second line
Miconazole oral gel
Oral
5ml QDS
7-14 days
Comments
Alternative regimen:
Fluconazole 50mg OD PO for 7-14 days (see comments
for oropharyngeal candidiasis).
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OROPHARYNGEAL CANDIASIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
Candida albicans
First line
Fluconazole
Oral
50mg OD
7-14 days
Treatment Regimen
Second line
Discuss with Medical
Microbiology/Infectious Diseases
after culture and sensitivity tests
Comments
This may be associated with HIV infection and/or
immunosuppression. Treatment of these patients
should be supervised by a senior clinician.
In unusually difficult infections/
immunosuppression/HIV infection higher doses and
longer durations of treatment may be needed e.g.
100mg OD for 14 days.
In other mucosal infections e.g. oesophagitis treat for
14-30 days.
ANGULAR CHEILITIS
Pathogen
Antimicrobial
Route
Dose
Duration of therapy
First line
Miconazole 2% cream
Topical
BD
Continue for 10 days after lesions
have healed
Treatment Regimen
Second line
Nystatin cream
Topical
BD – TDS
Continue for 7 days after lesions
have healed
Comments
Nystatin cream only available with Chlorhexidine.
Alternative regimen:
Fusidic acid 2% cream topically TDS – QDS
Treat according to swab results.
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HERPES SIMPLEX INFECTIONS
Pathogen
Herpes simplex virus
Antimicrobial
Route
Dose
First line
Aciclovir 5% cream
Topically to cold sores
5 times a day
Duration of therapy
5-10 days
Treatment Regimen
Second line
Aciclovir
Oral
200mg five times a day
Or
400mg TDS
5 days
Comments
Treatment should be started within 24 hours of
vesicles first appearing.
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Antibiotics should be given as SINGLE doses IV 0–30 minutes prior to skin incision.
NO routine post-operative antibiotics.
Administer entire dose at least 10 minutes prior to inflation of tourniquet.
Additional doses are not required unless blood loss >1500ml or the procedure lasts more
than four hours (further dose of cefuroxime) or eight hours (further dose of metronidazole).
Prophylactic antibiotics should be prescribed on the once only section of the prescription
chart.
Please refer to appendix 8 for advice on antibiotics in penicillin allergy.
GENERAL SURGERY
Procedure
Colorectal, small bowel
surgery
Appendicectomy
Open biliary surgery
Open pancreatic
surgery
Laparoscopic
cholecystectomy
Hernia repair with
mesh
Hernia repair (no
mesh)
Recommendation
Penicillin allergy
Cefuroxime 1.5g
Metronidazole 500mg
Ciprofloxacin 400mg
Metronidazole 500mg
MRSA colonisation
(current or previous)
None
Co-amoxiclav 1.2g
Teicoplanin 800mg
Gentamicin 160mg
Teicoplanin 800mg
Gentamicin 160mg
None
VASCULAR SURGERY
Procedure
Recommendation
Penicillin allergy
Amputation
Co-amoxiclav 1.2g
Teicoplanin 800mg
Gentamicin 160mg
Metronidazole 500mg
Open aneurysm repairs
EVAR or graft surgery
Teicoplanin 800mg
MRSA colonisation
(current or previous)
Add Gentamicin
160mg
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BREAST SURGERY
Antibiotic prophylaxis is indicated in surgery with >1risk factor for surgical site infection
Procedure
Recommendation
Penicillin allergy
MRSA colonisation
(current or previous)
Total duct excision
IV Co-amoxiclav 1.2g IV Teicoplanin 800mg IV Teicoplanin 800mg
Hydradenitis
IV Gentamicin 160 mg IV Gentamicin 160mg
Excision of mammary duct
fistula
Wire guided excisions
Previous RT
Post-chemotherapy
Colemans Fat Transfer
Nipple reconstruction in
PO Co-amoxiclav
PO Clarithromycin
patients with implant
625mg 30-60 mins
500mg 30-60 mins
prior to surgery
prior to surgery
Re Operations
IV Co-amoxiclav 1.2g IV Teicoplanin 800mg IV Teicoplanin 800mg
Evacuation of Haematoma
IV Gentamicin 160mg IV Gentamicin 160mg
Further wide local excision
Further axillary procedure
Cosmetic procedures
IV Co-amoxiclav 1.2g IV Teicoplanin 800mg IV Teicoplanin 800mg
Breast reduction
IV Gentamicin 160mg IV Gentamicin 160mg
Breast augmentation
Nipple reconstruction /
tattoo after implant
Reconstruction
Implant exchange
Free areola graft
Implant Reconstruction &
IV Co-amoxiclav 1.2g IV Teicoplanin 800mg IV Teicoplanin 800mg
High risk
IV Gentamicin 160mg IV Gentamicin 160mg
Implant reconstruction
LD flap reconstruction
TRAM flap reconstruction
Coleman Fat Transfer
Mammary Duct Fistula
Post radiotherapy
Total duct excision
Benign conditions
No antibiotic prophylaxis indicated
Lumpectomy
US guided biopsies
Lymph node biopsy
Gynaecomastia
Nipple tattoo
Nipple reconstruction
Malignant conditions
Wide local excision
Mastectomy
Sentinel lymph node
biopsy
Axillary node clearance
Therapeutic mammoplasty
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UROLOGICAL SURGERY
Procedure
TURP
Change of stents
Nephrostomy
Percutaneous
nephrolithotomy
Laparoscopic
Prostatectomy
TURT
Cystoscopy
Procedures involving
bowel
Transrectal ultrasound
guided (prostate)
biopsy
TRUB
(See separate Urology
policy for full details)
Recommendation
Penicillin allergy
Gentamicin 160mg
Gentamicin 160mg
Cefuroxime 1.5g
Metronidazole 500mg
Ciprofloxacin 400mg
Metronidazole 500mg
MRSA colonisation
(current or previous)
PO Ciprofloxacin 750mg STAT at least 1 hour before and PR Metronidazole
1g STAT at the end of the procedure
Patients will be discharged with 10 tablets of 250mg Ciprofloxacin to take
at 12 hourly intervals for 5 doses from evening of biopsy.
If patient cannot take Ciprofloxacin (allergy, epilepsy etc.) then give:
IV infusion of Gentamicin 160mg prior to the procedure and PR
Metronidazole 1gm STAT at the end of the procedure.
Patients will be discharged on co-amoxiclav 625mg 8 hourly for 8 doses
from 8 hours post biopsy.
RENAL SURGERY
Procedure
Renal Transplant
Recommendation
Penicillin allergy
Cefuroxime 1.5g
Ciprofloxacin 400mg
MRSA colonisation
(current or previous)
ENT SURGERY
Procedure
Recommendation
Penicillin allergy
MRSA colonisation
(current or previous)
No routine prophylaxis
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ORTHOPAEDIC SURGERY
Procedure
Recommendation
Penicillin allergy
MRSA colonisation
(current or previous)
Other information:
1) Unless specified otherwise a single dose of antibiotics should be given in theatre with no
post-operative ward administrated antibiotics
2) All potentially infected cases will be discussed at The Bone and Joint Infection Group
meeting and will be on a specific antimicrobial protocol decided by this group
Patients requiring post-operative catheterisation on the ward who have had implant surgery require
a single dose of Gentamicin 120mg IM on insertion or removal of the catheter
Non implant surgery
Primary Lower Limb
Arthroplasty - TKR, Uni
& THR & Upper Limb
surgery
(including those
requiring metal
implants)
Compound (open)
fractures
Revision Lower&
Upper Limb surgery
Spinal surgery
none
none
Cefuroxime 1.5g
Teicoplanin 800mg
Teicoplanin 800mg
Co-amoxiclav 1.2g
Clindamycin IV 600mg
8hrly or
pre-op/QDS
Cefuroxime 1.5g 8hrly
AND
Metronidazole 500mg
TDS (when
environmental
contamination is likely)
Continued until first debridement (excision).
The same dose should be given at the time of first debridement along with
a single dose of gentamicin (160mg). Antibiotics should be continued for a
maximum of 72 hours or soft tissue closure, whichever is sooner.
Gentamicin 160mg and teicoplanin 800mg should be administered on
induction of anaesthesia at the time of skeletal stabilisation and soft tissue
closure.
Cefuroxime 1.5g
Teicoplanin 800mg
Cefuroxime 1.5g
Limb reconstruction for bone infection should be given:
Teicoplanin 800mg OD
AND
Ciprofloxacin PO 500mg BD (750mg BD if severe infection)
Treatment should be extended until cultures are available when they
should be discussed with Medical Microbiology/Infectious Diseases
Cefuroxime 1.5g
Teicoplanin 800mg
Teicoplanin 800mg
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ERCP
Prophylaxis
Ciprofloxacin PO 750mg STAT
Other Information
IV ciprofloxacin 200mg may be given at the time
of procedure if oral dose has not been given
60-90 minutes pre-procedure
DO NOT give prophylaxis with ciprofloxacin If
patient is receiving antibiotic therapy for
cholecystitis/cholangitis.
If draining is not established post ERCP, continue
with antibiotic therapy.
SBP (SPONTANEOUS BACTERIAL PERITONITIS) PROPHYLAXIS
Primary Prophylaxis
Secondary Prophylaxis
Ciprofloxacin PO 500mg OD
Ciprofloxacin PO 500mg OD
In patients presenting who have a protein <15g/L This will be regularly reviewed by the
on an ascitic tap.
gastroenterology team and should be continued
until resolution of the ascites and improvement
This will be regularly reviewed by the
in liver function.
gastroenterology team and should be continued
until resolution of the ascites and improvement
in liver function.
CATHETERISATION
NOTE: For full policy see appendix 9
Antibiotic Prophylaxis Indicated
Prosthetic joint / implant <6 weeks
Removal of catheter following prostate surgery
Antibiotic Prophylaxis NOT Indicated
Patients with risk factors for infective
endocarditis
Patients with established prosthetic joints/ grafts
/implants
Painful / acute urinary retention
Based on one of the following risk factors:
Catheter insertion pre-surgery
- history of symptomatic catheter-associated
infection with previous catheter changes, OR
- purulent urethral / suprapubic catheter site
discharge, OR
- exit site colonisation with Staphylococcus
aureus, OR
- multiple traumatic attempts to catheterise
Catheter insertion for fluid monitoring
Painless/chronic urinary retention
Catheter insertion for incontinence
Suprapubic catheter insertion
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ENDOCARDITIS PROPHYLAXIS
Antibiotics have been offered routinely as a preventative measure to people at risk of infective
endocarditis undergoing interventional procedures. However, there is little evidence to support this
practice. Antibiotic prophylaxis has not been proven to be effective and there is no clear association
between episodes of infective endocarditis and interventional procedures. Any benefits from
prophylaxis need to be weighed against the risks of adverse effects for the patient and of antibiotic
resistance developing. As a result NICE recommends that antibiotic prophylaxis is no longer offered
routinely for defined interventional procedures.
Advice
Offer people at risk of infective endocarditis clear and consistent information about prevention,
including:
The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic
prophylaxis is no longer routinely recommended
The importance of maintaining good oral health
Symptoms that may indicate infective endocarditis and when to seek expert advice
The risks of undergoing invasive procedures, including non-medical procedures such as body
piercing or tattooing
Do not offer antibiotic prophylaxis against infective endocarditis:
To people undergoing dental procedures
To people undergoing non-dental procedures at the following sites1:
o Upper and lower gastrointestinal tract
o Genitourinary tract; this includes urological, gynaecological and
obstetric procedures, and childbirth
o Upper and lower respiratory tract; this includes ear, nose and throat procedures and
bronchoscopy
Do not offer chlorhexidine mouthwash as prophylaxis against infective endocarditis to people at risk
undergoing dental procedures.
Managing infection
Investigate and treat promptly any episodes of infection in prople at risk of infective
endocarditis to reduce the risk of endocarditis developing.
Offer an antibiotic that covers organisms that cause infective endocarditis if a person at risk
of infective endocarditis is receiving antimicrobial therapy because they are undergoing a
gastrointestinal or genitourinary procedure at a site where there is a suspected infection.
1
The evidence for this NICE guideline covered only procedures at the sites listed here. Procedures at
other sites are outside the scope of the guideline. See current BNF and NICE guidelines at
http://www.nice.org.uk/nicemedia/pdf/CG64NICEguidance.pdf
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SPLENECTOMY
Patients who suffer with asplenia or hyposplenia (including homozygous sickle cell disease and
coeliac syndrome) are at increased risk of overwhelming bacterial infection. Infection is most
commonly pneumococcal but other organisms such as Haemophilus influenzae type b and
meningococci may be involved.
This risk is greatest in the first two years following splenectomy, is greater amongst children but
persists into adult life. Animal and tick bites may be dangerous to splenectomised and functionally
hyposplenic patients. They are also at higher risk of severe malaria and should be counselled on
malaria prophylaxis (using most up to date guidelines) and given advice on avoidance of mosquito
bites.
A patient information leaflet is available from the department of health at:
http://www.patient.co.uk/health/preventing-infection-after-splenectomy-or-if-you-do-not-havea-working-spleen
Prophylaxis
This should be given at least for the
immediate postoperative period in patients
undergoing splenectomy. It should be
continued in patients under 16 or over 50
years of age, in patients considered to be at
high risk of infection (e.g. poor vaccine
responders) and in patients who opt for
continued treatment after counselling as to
risk.
Penicillin V 250mg BD PO
Or in case of penicillin allergy:
Erythromycin 500mg BD PO
Vaccination
This advice applies to adults (separate advice is
available for children). Where possible, patients
should be immunised two weeks or more before
splenectomy. If this is not possible immunisation
should occur approximately two weeks after
surgery.
Initially, patients should receive:
Pneumococcal vaccine1 (Pneumovax II)
Combined Haemophilus influenza Type B
/Meningicoccus Group C conjugate
vaccine (Menitorix)
Approximately 1 month later, patients should
receive:
Meningococcus ACWY conjugate vaccine
(Menveo or Nimenrix)
Patients should also receive:
Influenza vaccine – every winter
1: There is an argument for assessing the pneumococcal antibody response 4–6 weeks after
immunisation with Pneumovax, as unresponsive patients may benefit from immunisation with the
conjugated pneumococcal vaccine. For Pneumovax responders, re-vaccination is advised every 5
years by default, or at intervals guided by the antibody response.
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MENINGITIS
Chemoprophylaxis aims to reduce the risk of invasive disease by eradicating carriage in a group of
close contacts at highest risk.
Discuss need for chemoprophylaxis with Medical Microbiology/Infectious Diseases.
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Appendix 1
Once Daily Gentamicin Dosing Protocol
Background
Once daily gentamicin dosing has a number of benefits over traditional dosing:
It is more likely to achieve target peak drug concentrations
It associated with less toxicity
It is more economic and much easier to monitor
It is therefore preferable to use once-daily gentamicin dosing (where appropriate) in those patients
requiring therapy with this antibiotic.
Exclusions to once-daily dosing
Endocarditis
Ascites
Paediatrics
Patients requiring single doses/prophylaxis
Dialysis patients
Pregnancy & post-partum
Major burns (>20% BSA)
Cystic fibrosis
Mycobacterial infections
Creatinine clearance <20ml/min
Dosing
Use the gentamicin dose calculator (based on ideal body weight/IBW)
Gentamicin dose = 5mg/kg (maximum 450mg)
Dilute in 100ml of glucose 5% or sodium chloride 0.9% and administer by IV infusion over 1 hour.
Use ideal body weight (IBW) to calculate the dose.
If patient is >20% above IBW use obese dosing body weight (ODW)
If patient is underweight use actual body weight
IBW (male) = 50Kg + (2.3 x inches over 5 feet)
IBW (female) = 45.5Kg + (2.3 x inches over 5 feet)
ODW = IBW + 0.4 (actual body weight – ideal body weight)
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Selection of Dosing Interval
This is based on the patient’s renal function. Creatinine Clearance (CrCl) should be calculated using
the Cockcroft and Gault equation:
CrCl = F x (140 – age) x weight (Kg)
Serum Creatinine (micromoles/L)
Where F = 1.23 males and 1.04 females. Use actual body weight or use ODW if the patient is obese.
CrCl (ml/min)
Dosing Interval (Hours)
>=60
24
40 – 59
36
20 – 39
48
<20
Do not use nomogram, contact Medical Microbiology or
Pharmacy for advice).
INSTRUCTIONS FOR USE
NOTE: Contact Pharmacy or Medical Microbiology for dosing advice
1. Patient requiring gentamicin therapy identified.
2. Check exclusion criteria to see if patient is eligible for once-daily gentamicin dosing.
If eligible continue with point 3, otherwise contact Pharmacy or Medical Microbiology for
further dosing advice.
3. Calculate the required dose using the gentamicin calculator
Gentamicin dose = 5mg/kg (maximum 450mg)
4. Obtain a single serum drug level 8 – 12 hours after the start of the first infusion.
It is imperative that the time between administration and taking the blood sample is
recorded accurately and documented on the request form.
5. Adjust dose according to the Barnes-Jewish Hospital nomogram. If the point is on a line
dividing intervals, choose the longer interval.
6. If the level is off the nomogram at the given time, stop the scheduled therapy and obtain
further dosing advice from Pharmacy or Medical Microbiology.
7. Repeat pre dose (trough) drug levels 1 – 2 times weekly and serum creatinine 2 – 3 times
weekly (depending on the patient’s condition more monitoring may be needed). Target
pre-dose levels <1mg/L.
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Further advice
During working hours (Monday to Friday, 09:00 – 17:00)
Pharmacy
Medicines information extension 2096
Anne Neary (Antibiotic/Infectious Diseases Pharmacist) bleep 4502
Kate Vaudrey (Antibiotic/Admissions Pharmacist) bleep 4980
Medical Microbiology
Extension 4410
Out of hours
On-call Microbiologist Via Royal Liverpool switchboard
On-call Pharmacist Via Royal Liverpool switchboard
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Appendix 2
Guideline for Teicoplanin Dosing in Adults
Background
Teicoplanin is a glycopeptide antibiotic with very similar activity to vancomycin. It is used to treat
serious Gram positive bacterial infections including MRSA, S. epidermidis and enterococcal
organisms. Teicoplanin is not absorbed orally and is therefore only given by the parenteral route. It
has good penetration into soft tissue, joints and bone and may be given as a bolus injection or an
infusion over 30 minutes. This makes it particularly suitable for surgical prophylaxis in patients with
either true penicillin allergy or the presence of MRSA.
Teicoplanin is reserved for:
1. Treatment of severe MRSA infections
2. Treatment of other serious staphylococcal, streptococcal and enterococcal infections
including endocarditis where:
i. resistance to the more commonly used β-lactam agents exists
ii. patient has true β-lactam allergy
3. Treatment of bone and joint infections, infective endocarditis or vascular graft infections
where long-term outpatient antimicrobial therapy (OPAT) is suitable (and where there is no
oral option available or indicated)
4. Other severe Gram positive bacterial infections as advised by microbiology. The rationale for
glycopeptide therapy should be documented in clinical notes.
5. Surgical prophylaxis in patients either allergic to penicillins, or requiring cover against MRSA.
General points
1. The relationship between serum concentration and toxicity has not been established.
2. For mild-to-moderate infection, there is little evidence to support serum monitoring unless
abnormal renal clearance is anticipated e.g. in intravenous drug abusers, elderly or renally
impaired patients [Darley et al 2004].
3. In severe infections such as septicaemia, joint infection and endocarditis, the relationship
between outcome and trough concentration is well documented. Serum monitoring should
be used to optimise therapy [Darley et al 2004, Harding et al 2000].
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4. The pharmacokinetics of teicoplanin are unpredictable with considerable inter-individual
variability in the serum concentration of patients given the same doses [MacGowan et al
2004].
5. Teicoplanin is less likely to cause nephrotoxicity than vancomycin when co-administered
with aminoglycoside and ‘red man syndrome’ is rare with teicoplanin *Wilson 1998+.
Dosing
Teicoplanin 1.2g STAT dose on day 1, then 800mg OD thereafter
Please note – the above doses are higher than those recommended by the manufacturer and use at
these doses is therefore outside of the product licence.
These doses have been considered by the Medicines Management Group and are approved for use
by the Trust, so unlicensed consultant responsibility forms do not need to be completed for these
doses.
For any doses exceeding these (1.2g) clear reasoning must be documented in the patient’s case
notes and the Consultant looking after the patient must be aware and complete a consultant
responsibility form which should be returned to pharmacy.
Deviation from this guideline may occasionally be justified and the rationale clearly recorded in
the clinical record
Renal Impairment
In renal impairment reduction in dose is not required for the first 3 days (initiate dose reduction
from Day 4)
CrCl (ml/min)
Dose Reduction
20-50
Dose as in normal renal function
10-20
Give full dose every 2nd day (48hours)
<10
Give full dose every 3rd day (72 hours)
Dialysis patients
In Dialysis patients an initial loading dose of 1.2g should be given and then 800mg given three times
a week after HD
Serum levels will aid more accurate dosing
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Serum concentration monitoring
Inclusion criteria
Serum concentration monitoring is required in patients who:
1. Present with severe infections such as septicaemia or deep seated staphylococcal infection
(including bone and joint infection)
2. Are intravenous drug abusers
3. Present with burns
4. Present with impaired, deteriorating, or unstable renal function
5. Undergo renal replacement therapy (CRRT, HD and PD)
Exclusion criteria
Serum concentration monitoring is NOT required for all other patients who do not fulfil the inclusion
criteria
When to take levels
Trough (pre-dose) level immediately BEFORE
giving the dose on the 3rd or 4th day
Assay frequency
Once a week or less frequently if stable
Give dose. Do not wait for levels
TROUGH (PRE-DOSE) LEVEL : Aim for >10mg/L, but <60mg/L
For endocarditis, osteomyelitis and septic arthritis, aim for >20mg/L
IMPORTANT
Sample should be collected in a
white tube (serum sample) separate
from any other tests
Sample details must be recorded on the
microbiology assay request form
Teicoplanin assays are routinely run
3 times per week
Administration
Instructions for reconstitution:
Add diluent provided (WFI) slowly to vial and roll it gently until the powder dissolves. Take care to
avoid formation of foam. If it does foam, leave the vial to settle for 15 minutes until it subsides.
Method and rate of administration:
For doses up to (and including) 1.2g
Give as an IV bolus over 3 – 5 minutes OR as a slow IV infusion over 30 minutes.
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Contacts
During working hours (Monday to Friday, 09:00 – 17:00)
Pharmacy
Medicines information extension 2096
Anne Neary (Antibiotic/Infectious Diseases Pharmacist) bleep 4502
Kate Vaudrey (Antibiotic/Admissions Pharmacist) bleep 4980
Medical Microbiology
Extension 4410
Out of hours
On-call Microbiologist via Royal Liverpool switchboard
On-call Pharmacist via Royal Liverpool switchboard
References
rd
Ashley C, Currie A (Ed). The Renal Drug Handbook. 3 Ed 2009, Radcliffe Publishing Ltd, Oxford.
Darley ESR, MacGowan AP. The use and therapeutic drug monitoring of teicoplanin in the UK. Clin
Microbiol Infect 2004; 10:62-69
Elliott TSJ, Foweraker J, Gould FK, Perry JD, Sandoe JAT. Guidelines for the antibiotic treatment of
endocarditis in adults: report of the Working Party of the British Society for
Antimicrobial Chemotherapy. J Antimicrob Chemother. 2004; 54:971-981
Harding I, MacGowan AP, White LO, Darley ESR, Reed V. Teicoplanin therapy for Staphylococcus
aureus septicaemia: relationship between pre-dose serum concentrations and outcome. J
Antimicrob Chemother. 2000; 45:835-841
MacGowan A, White L, Reeves D, Harding I. Retrospective review of serum teicoplanin
concentrations in clinical trials and their relationship to clinical outcome. J Infect Chemother. 2000;
2:197-208
Wilson APR. Comparative safety of teicoplanin and vancomycin. Int J Antimicrob Agents 1998; 10
(1):143-153
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Appendix 3
Trust Clinical Policy
Pharmacy
Antimicrobial Stop / Review Date and Indication Policy
Policy Reference:
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Table of Contents
Heading
Page Number
1.0
Introduction
2.0
Objective
3.0
Scope of Policy
4.0
Policy
5.0
Roles and Responsibilities
6.0
Associated documentation and references
7.0
Training & Resources
8.0
Monitoring and Audit
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1. Introduction
Correct use of Antimicrobial agents requires that prescriptions are reviewed on a regular basis to
ensure that the selected agent is still appropriate, continuation of therapy is still necessary and the
route is still appropriate.
The antibiotic point prevalence study conducted in November 2005 at Queens Medical Centre
showed that 85% of all antibiotic prescriptions did not have an intended stop date. There have been
incidences where patients received unnecessarily long and excessive treatment, as a result of
therapy not being reviewed. This can have an impact on:
increased selection of resistance organisms
antibiotic treatment related illnesses e.g. Clostridium difficile diarrhoea
increased risk of adverse effects
increased expenditure
The Trust has a clear mandate to reduce infections from drug resistant pathogens e.g.MRSA and
Clostridium difficile (C.diff). A major part of this battle is the reduction of unnecessary antibiotic use.
A recently published study confirmed the increased risk of C. diff. diarrhoea with longer duration for
many of the commonly used antibiotic classes:
In general 1-3 days caused a lower risk than 4-6 days which caused a lower risk than 7 or more
days, for some classes these differences were significant.
The addition on the medicine chart of a stop date or intended duration of treatment every time an
order for an antimicrobial agent is made, has worked successfully in many hospitals. Pharmacists
and nurses facilitate the policy as part of their role on the wards.
The indication for an antimicrobial agent is often not clear or easy to find in the notes and makes
monitoring for appropriateness by other clinicians and health professionals difficult. In many cases
the prescriber initiating the antimicrobial may not be available to regularly review it (due to shift
working). It would therefore be very beneficial to have the indication written on the medicine chart
for all orders of antimicrobial agents.
Overall, documenting the indication and intended stop date/duration on the drug card will be
beneficial to all and help prevent unnecessarily extended antibiotic courses.
2. Objectives
2.1. An indication and stop/review date or intended duration should be indicated on the
medicines chart at the point of prescribing of all antimicrobials
2.2. The overall objective of this policy is therefore to prevent unnecessarily extended courses
of antibiotics and consequently reduce the risk of Clostridium difficile for patients.
3. Scope of the Policy
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The policy applies to all clinical staff involved the prescribing of antimicrobials
4. Policy
4.1. Actions for Doctors
4.1.1.
Write the indication and stop/review date or intended duration in the ‘additional
instructions’ box on the medicine chart for each antimicrobial agent prescribed.
For EPMA prescriptions, an automatic stop date can be created at the time of
prescribing, and the required number of days or doses can be selected (figure 1).
Figure 1. EPMA screen shot – automatic stop date
For infections where an automatic stop date is not appropriate, create an antimicrobial therapy note
by selecting the ‘add note’ button for each antimicrobial agent prescribed. Details of the review
date can be added in this note. Write the indication for all antimicrobial prescriptions in the
antimicrobial therapy note (figure 2).
The indication should be as specific as is known at the time of prescribing eg. “Sepsis ?cause” may be
appropriate if there really are no clinical features. This should be updated as more information is
available.
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Figure 2. EPMA screen shot – Antimicrobial therapy note with indication & review date
4.1.2.
The majority of intravenous antimicrobials will require a “review” rather than a
“stop” date prior to being converted to oral
4.1.3.
Review doses should be targeted for lunchtime doses where possible and should
avoid weekends unless the patient is due for daily consultant review.
4.1.4.
When review of the antimicrobial takes place this should be documented on the
medicine chart e.g. crossing through “r/v” and writing “give” plus endorsing a
new review date
4.1.5.
For some infections, e.g. empyema, it may be difficult to endorse a definite stop
date until the patients condition begins to improve. Antimicrobials in these
circumstances should have review dates about twice a week e.g. at consultant
ward rounds and/or Fridays
4.1.6.
When an intravenous antimicrobial is changed to an oral antimicrobial, please
indicate the duration as either:
“…days more” i.e…. days of oral following IV therapy,
“…days total” i.e. the total required duration of IV and PO together or put
a stop date (e.g. stop 02/04/07)
4.1.7.
Antimicrobials should be stopped/reviewed earlier than indicated if clinically
indicated.
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Figure 3. Paper drug chart with stop date (most appropriate for oral therapy)
Times to
be given
REGULAR PRESCRIPTIONS
Date
month
21/07 22/07 23/07 24/07 25/07 26/07 28/07 29/07 30/07 31/07
Medicine
Trimethoprim
08.00
Trimethoprim
Dose
Route
200mg
PO
Additional Instructions/ Indication
Stop date/Sig
24/7 AD
PO
20.00
Prescribers Signature
Bleep
A Doctor
1234
Start date
21/7
A Doctor
Figure 4. Paper drug chart with review date (most appropriate for initial IV therapy)
Times to
be given
REGULAR PRESCRIPTIONS
Date
month
21/07 22/07 23/07 24/07 25/07 26/07 28/07 29/07 30/07 31/07
Medicine
Flucloxacillin
08.00
Fucloxacillin
R/V
Dose
2g
Route
IV
Additional Instructions/ Indication
Stop date/Sig
14:00
Cellulitis – review 48hrs
IV24/7
Prescribers Signature
Start date
A Doctor
Bleep
1234
21/7
18:00
AD
22:00
A Doctor
4.1.8.
Course Lengths
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Most common infections will respond to five days of antimicrobials. However Clinical judgement is
still required, some patients/minor infections will not require the full standard course length while
others may require extended courses.
Common exceptions are:
Uncomplicated UTIs in non-pregnant women
Complicated UTIs in women, UTIs in men or pregnant women - 7 days
Endocarditis, meningitis, osteomyelitis, septic arthritis, tuberculosis, bronchiectasis
and immunocompromised patients - often require long courses
Non severe community acquired pneumonia- BTS recommend 7 days
Severe, microbiologically undefined pneumonia-BTS recommend 10 days.
Legionella, staphylococcal or Gram negative enteric bacilli pneumonia- BTS
recommend 14-21 days
Surgical prophylaxis - see formulary
Intravenous line infections with positive blood cultures-often require longer courses
4.1.9.
Missed Doses
Antimicrobial doses may be missed for a number of reasons (e.g. no cannula, unable to swallow).
Patients should be reviewed clinically and consideration given for represcribing additional doses if
required.
4.2. Actions for Nurses
4.2.1.
Request the doctor to write the stop/review date and indication on the medicine
chart or on EPMA for all orders of antimicrobial agents
4.2.2.
Query all prescriptions continuing beyond the stop/review date
4.2.3.
Whilst awaiting review, continue to administer the antimicrobial
4.2.4.
Ask doctor to review if a number of doses have been missed during the
prescribed course, especially if the patient is still unwell or at a weekend where
regular review is unlikely.
4.3. Actions for Pharmacists
4.3.1.
All Pharmacists should request a stop/review date and indication to be written in
the ‘additional instructions’ box on the medicine chart or as a note on EPMA for
all antimicrobial agents
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4.3.2.
If the prescription is written in the presence of a Pharmacist, request a
stop/review date and indication as part of the prescription writing process.
4.3.3.
If a stop date has been documented the Pharmacist may alter the administration
boxes to ensure nurses do not give a longer course than was intended.
Figure 5. Paper drug chart – Pharmacist alteration of administration boxes
Times to
be given
REGULAR PRESCRIPTIONS
Date
month
21/07 22/07 23/07 24/07 25/07 26/07 28/07 29/07 30/07 31/07
Medicine
Amoxicillin
08.00
AN
14:00
AN
22:00
AN
AN
Amoxicillin
Dose
Route
500mg
PO
Additional Instructions/ Indication
Stop date/Sig
Non severe CAP – 7 days
PO
29/07 AN
Prescribers Signature
Start date
A Doctor
Bleep
1234
21/7
A Doctor
4.3.4.
If a review date has been documented by the doctor, the pharmacist should
highlight and endorse ‘R/V’ around the appropriate administration box. If
possible, choose a weekday lunchtime dose:
Figure 6. Paper drug chart – Pharmacist highlighting review date
REGULAR PRESCRIPTIONS
Times to
be given
Date
month
21/07 22/07 23/07 24/07 25/07 26/07 28/07 29/07 30/07 31/07
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Medicine
08.00
Flucloxacillin
R/V
Fucloxacillin
Dose
Route
2g
IV
14:00
Additional Instructions/ Indication
Stop date/Sig
Cellulitis – review 48hrs
IV
Prescribers Signature
Start date
A Doctor
Bleep
1234
21/7
18:00
22:00
A Doctor
4.3.5.
For all prescriptions already written, contact the prescriber and request a stop
date and indication then endorse the chart appropriately. Inform the prescriber
that the standard is to include a stop date and indication every time an order for
an antimicrobial agent is made. This request should be made within 48-72 hours
of the prescription being written.
4.3.6.
If this is not possible write in the notes requesting for a stop date and indication
for the antimicrobial agent, and if appropriate annotate the chart using a course
length review or IV/PO switch sticker.
4.3.7.
If the stop date has not been written by day 5 of treatment, inform the prescriber
that this will be referred to the Antibiotic Pharmacist and Consultant
Microbiologist if the indication/stop date are not written on the medicine chart
for the antimicrobial on day 7 of treatment.
4.3.8.
If the stop date has not been written by day 7 of treatment, refer the patient to
the Antibiotic Pharmacist and/or Consultant Microbiologist.
5. Roles & Responsibilities
5.1. All clinical staff involved in the prescribing of antimicrobials to adhere to this policy
including full documentation on medicine charts as detailed.
5.2. Antibiotic Management Group to maintain and update this policy
6. Associated documentation and references
6.1. Queens Medical Centre Antimicrobial Point Prevalence Study November 2005
6.2. Pepin et al Clin. Inf. Diseases 2005:41 1254-1260
7. Training & Resources
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Prescribers will be trained by means of this policy document, the RLBUHT Formulary and awareness
sessions run by Medical Microbiologists and Pharmacists.
8. Monitoring and Audit
8.1. An audit will be performed 3 months after initiation of the policy to estimate concordance
8.2. The annual point prevalence study will provide further monitoring of concordance with
the policy
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Appendix 4
Trust Clinical Policy
Pharmacy
Antimicrobial IV to PO Switch Policy for Clinical Pharmacists
Policy Reference:
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Document Control
Document Title
Antimicrobial IV to PO switch policy for Clinical
Pharmacists
Author/Contact
Ms Anne Neary
Document Path & Filename
Document Reference
Version
1.1
Status
Approved
Publication Date
October 15th 2007
Review Date
September 30th 2008
Approved by (Executive)
Alison B Ewing
Date: Sept 2007
Ratified by (Relevant Group)
Clinical and Cost Effectiveness
Group
Date: Oct 2007
Distribution:
Royal Liverpool and Broadgreen University Hospitals NHS Trust-intranet
Please note that the Intranet version of this document is the only version that is maintained.
Any printed copies must therefore be viewed as “uncontrolled” and as such, may not necessarily
contain the latest updates and amendments.
Document History
Version
Date
Comments
Author
1.0
RLBUHT Antibiotic Management
Group
Ms Andrea Battersby
1.1
RLBUHT Antibiotic Management
Group
Ms Anne Neary
Review Process Prior to Ratification:
Name of Group/Department/Specialist Committee
Date
Antimicrobial Management Group
August 2007
Medicines Management Group
August 2007
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Table of Contents
Heading
1.0
Introduction
2.0
Objective
3.0
Scope of Policy
4.0
Policy
5.0
Roles and Responsibilities
6.0
Associated documentation and references
7.0
Training & Resources
8.0
Monitoring and Audit
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1.0 Introduction
Oral antibiotic therapy has been shown to be as effective as intravenous antibiotics for many
infections. Intravenous antibiotic therapy carries the additional risks of phlebitis, sepsis and
increased hospital stay compared with oral therapy.
A pilot study in University Hospital Aintree medical inpatients showed that around 50% of
intravenous antibiotic courses could have been stopped or swapped to oral sooner than actually
occurred.
2.0 Objectives
The overall objective of this policy is to reduce the inappropriate use of IV antibiotics
By doing this the policy also aims to reduce the risks associated with unnecessary cannulation
mentioned above.
3.0 Scope of the Policy
3.1 The policy applies to all clinical staff involved the prescribing of intravenous
antibiotics.
3.2 The policy only applies to prescriptions for patients that fulfil all of the inclusion
criteria.
3.3 The policy does not apply to prescriptions for patients that meet any of the
exclusion criteria.
4.0 Policy
4.1 The Pharmacist identifies patients on IV antibiotics on their wards during daily wards
visits.
4.2 The patient’s condition is checked against the hospital policy to assess suitability for
a change in route of administration of antibiotic from intravenous to oral and when
the course should finish.
4.3 A patient must satisfy ALL of the inclusion criteria to be suitable for oral treatment:
Documented or suspected infection
Patient is improving on intravenous therapy with a temperature of <38 C for >48
hours and no unexplained tachycardia
Patient is able to take oral fluids
Patient has no potential absorption problems
There is a suitable oral antibiotic available
The professional judgement of the pharmacist agrees that it is appropriate.
4.4 A patient is NOT suitable for oral treatment if they satisfy any of the exclusion
criteria:
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Meningitis, endocarditis, septic arthritis, osteomyelitis, bronchiectasis, neutropenic
or immunocompromised patients.
Nil By Mouth patients
Patients at risk of aspiration
Patients with severe nausea, vomiting, diarrhoea, gastro-intestinal obstruction or
motility disorder
Patients having continuous naso-gastric suctioning
Patients at the end of their antibiotic course
Patients with infections where the culture and sensitivity results show that the
organisms are unlikely to be susceptible to oral antibiotics
Patients who have not yet completed the course of intravenous antibiotics specified
by their consultant or registrar on their prescription chart or case notes
4.5 If the patient is a candidate to be changed from intravenous antibiotics to oral
antibiotics the pharmacist will contact a medically qualified member of the
appropriate consultant’s team to discuss the case. The pharmacist will suggest a
suitable antibiotic and dose according to microbiologist reports/advice, the hospital
formulary for empirical therapy, patients’ allergies, other conditions and
renal/hepatic function.
The oral antibiotic does not necessarily need to be from the same class as the
intravenous antibiotic but should have similar spectrum of activity and tissue
penetration. The Pharmacist should suggest an appropriate length of course
according to the hospital formulary if it is not clear from the prescription.
4.6 If the doctor agrees that the pharmacist’s suggestions are appropriate the doctor
should rewrite the prescription accordingly. If the doctor agrees to the changes but
is not available to change the prescription the pharmacist will be authorised to
rewrite the prescription on behalf of the doctor; this includes adding a new drug,
dose and route of administration, adding finish dates for antibiotic courses and
blanking administration boxes to ensure that unnecessary doses are not given as
appropriate. The authorising doctor must countersign the prescription at the earliest
opportunity.
4.7 The Pharmacist must document any changes they have made in the patient’s
medical case notes, along with the name and pager number of the doctor they
discussed the case with.
5.0 Roles & Responsibilities
All prescribers and pharmacists to adhere to this policy when treating patients with intravenous
antibiotics, including full documentation of any changes made in the patients case notes.
Antibiotic Management Group to maintain and update this policy
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6.0 Associated documentation and references
Sevinc F et al, Early switch from intravenous to oral antibiotics: guidelines and implementation in
a large teaching hospital. Journal of antimicrobial chemotherapy (1999) 43, 601-606
Laing et al, The effect of intravenous-to-oral switch guidelines on the use of parenteral
antimicrobials in medical wards. Journal of antimicrobial chemotherapy (1998) 42: 107-111
7.0
Training & Resources
Prescribers will be trained by means of this policy document, the RLBUHT Formulary and
awareness sessions run be Medical Microbiologists and Pharmacists.
8.0 Monitoring and Audit
The usage and costs of intravenous and oral antibiotics will be monitored monthly by the
Antibiotic Pharmacist and reviewed by the Antibiotic Management Group
An audit will be performed 3 months after initiation of the policy and a point prevalence audit
carried out annually, to monitor concordance with the policy.
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Appendix 5
Trust Clinical Guidelines
Bone and Joint Infection Group
Guidelines for the Management of Bone & Joint Infections
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Contents
1. Introduction
2. Principles of Management
a. Clinical Features
b. Diagnosis
c. Goal setting
d. Medical Management
e. Surgical Management
f. Interdisciplinary issues
3. Vertebral Osteomyelitis and Discitis
4. Spinal Epidural Abscess
5. Spinal Implant Infection
6. Acute Osteomyelitis
7. Acute Septic Arthritis (Native Joint)
8. Acute Prosthetic Joint Infection
9. Chronic Prosthetic Joint Infection
10.Chronic Long Bone Osteomyelitis (not diabetic foot)
11.Diabetic Foot Infection excluding osteomyelitis
12.Diabetic Foot Infection including osteomyelitis/septic arthritis
13.References
Appendix 1: Organism Specific antibiotic treatment
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1. Introduction
These guidelines have been prepared on behalf of the RLUH Bone and Joint Infection Group
(BJIG) a multi-disciplinary forum of orthopaedic surgeons, medical microbiologists,
musculoskeletal radiologists, diabetologists and infectious disease physicians. Particular
acknowledgement is given to Dr Miriam Taegtmeyer who wrote the original draft of the
guidelines.
The guidelines are intended to provide guidance in the management of bone and joint
infections at the Royal Liverpool University Hospital. They are primarily concerned with
medical aspects of patient care and rely on excellent working relationships between the
medical and orthopaedic teams. They are aimed at surgeons, anaesthetists, junior medical
and surgical staff as well as ward nurses caring for bone or joint infections.
Doses of antibiotics given in this guidance document may need to be adjusted for renal
impairment. Please refer to the British National Formulary and the Renal Handbook for
further details of cautions, contra-indications, side-effects and dose.
For complex enquiries regarding antibiotics or management please contact the department
of Microbiology or Infectious diseases on the contact numbers outlined below.
Microbiology
Infectious Disease Service
PICC line insertion
Pharmacy
Working Hours (Mon-Fri 9am Out of Hours
to 5pm)
Dr Jonathan Folb
Via switchboard
0151 706 4425/4413
Dr Alastair Miller
Via switchboard
0151 706 3836
Dr Nick Beeching
0151 706 3835
SpR via switchboard
Helen Harker via switchboard
Anne Neary bleep 4502
Katie Barnett bleep 4967
Kate Vaudrey bleep 4980
Via switchboard
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2. Principles of Management
a. Clinical features
In bone and joint infections the pain may be disproportionate to the findings. There
is often accompanying swelling, stiffness, tenderness or loss of function. Fever is a
sign of acute infection, whereas chronic infection may be characterised by wound
drainage and sinus formation. A chronic ulcer, especially if bone is exposed, should
alert the clinician to the possibility of underlying bone infection.
b. Diagnosis
Some or all of the following diagnostic tests should be undertaken. The aim is to
understand the extent of infection, the degree of inflammation and to isolate the
responsible pathogen.
FBC/U&Es/LFTs/ESR/CRP
Blood cultures
Plain X-ray,
MRI/CT
Operative tissue samples for histology and at least five samples for microbiology.
This is of vital importance when guiding decisions on antibiotics.
Aspiration arthrogram or other biopsy
c. Goal setting
Be clear from the outset what the aims of treatment are. In the management of
bone and joint infections it is especially important to work as a multidisciplinary
team and to involve the patient in decisions about treatment. There must be good
communication between orthopaedic surgeons, Microbiology, Infectious Diseases,
Radiology and other support teams.
d. Medical management – Infectious Diseases & Microbiology
The priority is to stabilise the patient. The clinician should be aware of and treat comorbidities. It is important to stabilise nutrition. Appropriate empiric and culturedriven antibiotics are needed in conjunction with surgical management.
In general antimicrobials should be withheld until after sampling has been
undertaken, unless the patient is acutely unwell.
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i) Choice of empirical intravenous agent
The details of empirical recommendations may vary according to the condition
being treated and are therefore outlined in the specific subsections below. In
general all patients should be triaged to assess their risk of nosocomial
infections. If a patient is known to be MRSA positive use a regimen containing
teicoplanin.
For community acquired infections:
Cefuroxime 1.5g TDS IV
For all patients with a previous history of trauma, surgery or intravenous
catheterisation; nosocomial infections should therefore be covered empirically
with:
Teicoplanin 1.2g loading dose then 800mg OD IV
+
Ciprofloxacin 750 mg BD PO
(Unless the patient is nil by mouth or major problems with vomiting/oral absorption are
encountered or anticipated. NB IV dose is not equivalent to oral dose).
In the event of major wound contamination:
Teicoplanin 1.2g loading dose then 800mg OD IV
+
Meropenem 1g TDS IV
(Should be used instead of ciprofloxacin to cover anaerobic organisms and extended
spectrum beta lactamases – ESBLs).
Ciprofloxacin or meropenem can be discontinued if there has been no growth of
gram negative organisms at 72 hours. The decision to continue antibiotics should
be made on the basis of the scans, the pre and intra-operative suspicion of
infection, histological appearances and microbiological evidence, with greater
than 3 out of the five samples positive at 5 to 7 days having a high positive
predictive value of infection.
ii) Choice of antibiotics when culture positive:
For methicillin sensitive staphylococcus aureus (MSSA) give IV beta-lactams:
Flucloxacillin 2g QDS IV (While in hospital)
or
Ceftriaxone 1-2g OD IV once PICC line inserted and home IV team
involved.
In the event of penicillin allergy or other positive cultures discuss with
Microbiology/Infectious Diseases.
For resistant organisms such as MRSA, give glycopeptides such as IV Teicoplanin.
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Once a PICC line is inserted and the home IV team is involved, then doses of
800mg on Mondays and Wednesdays and 1.2g on Fridays can be prescribed.
A teicoplanin trough level should be taken on day 3 or 4 of treatment (refer to
Teicoplanin policy in Antimicrobial Formulary – appendix 2).
For these and all other organisms, including gram negative organisms, it is
important to be guided by laboratory results and the microbiologists
iii) Culture negative bone and joint infections
These may also require treatment. Further investigation should be undertaken
for Lyme, Brucella, Bartonella etc. depending on epidemiology. If there is clinical
suspicion of infection taken together with suspicious histology then infection
should usually be treated as for infections with Gram-positive organisms. Liaison
with microbiology in such cases is important.
iv) Duration of therapy
This varies according to condition, and there is little consensus internationally 1.
The local guidance for treatment may be found outlined under the specific
conditions below. Individual clinical decisions may be informed by clinical
progress, monitoring of inflammatory markers and by imaging.
v) Oral step-down therapy:
By the time decisions are made about oral therapy full sensitivities on
culture positive organisms should be available, and decisions regarding
choice of oral agent should usually be discussed with Infectious Diseases
or Microbiology.
There is some evidence for early step down but this is not the standard,
and these guidelines advocate prolonged intravenous therapy in the
majority of cases.
e. Surgical management – orthopaedics and plastics
Prophylaxis
Abscess drainage
Washout of Joints
Excision of dead tissue, dead bone, foreign materials (unless conserving
implants)
Adequate sampling2
Management of dead space
Ensuring soft tissue coverage
Ensuring skeletal stability
Staged vs immediate reconstructive work
Local antibiotic delivery
f. Interdisciplinary issues
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Interdisciplinary issues are key and good communication through MDT meetings is
vital when discharge planning.
Most patients receiving treatment for bone and joint infections require longterm IV access and the insertion of a PICC or Hickman line is beneficial as it
allows patients to go home and receive once daily IV antibiotic regimens.
Home IVs – close liaison with the home IV team, district nurses or through
direct training of the patient or their carers means that only the initial period
of intravenous antibiotics need be administered in hospital, thus improving
quality of life for the patient and reducing hospital in-patient stays3
Pain control
Wound Care
Physiotherapy
Occupational therapy
Drug dependency
Psychological impact of disease
Rehabilitation medicine, prosthetics and orthotics
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3. Vertebral Osteomyelitis and Discitis
a) Clinical features
These are back pain (severe, unremitting, worse in positions that load the spine,
night pain common); malaise and anaemia of chronic disease. Occasionally these
infections may present as pyrexia of unknown origin (PUO). Patients may have
neurology if there is an associated epidural abscess or retropulsion of disc contents.
b) Diagnosis
Blood cultures
FBC, ESR, U&Es, LFTs, CRP
MRI of spine
Percutaneous bone biopsy is often performed for culture and histology.
Chest X-ray if TB suspected
Brucella and Bartonella serology if culture negative
c) Goal setting
Minimise neurological damage and eradicate infection.
d) Medical management
As this is a chronic condition it is usually possible to await the result of cultures and
biopsy before commencing treatment. In systemically unwell patients start empirical
intravenous antibiotics after doing blood cultures. If blood cultures isolate an
organism that is likely to be clinically relevant, then biopsy is not ordinarily
necessary. The possibility of tuberculous (TB) infection should always be considered
and ID consultation requested if TB is suspected.
i) Empirical IV antibiotics (septic patients only)
Teicoplanin 1.2g loading dose then 800mg OD IV
+
Ciprofloxacin 750 mg BD PO
(Unless the patient is nil by mouth or major problems with vomiting/oral absorption are
encountered or anticipated. NB IV dose is not equivalent to oral dose).
ii) Culture dependent IV antibiotics
For choice of drugs see general comments above under principles of
management (section 2).
iii) Duration of treatment
Usually 6 weeks of intravenous therapy followed by oral. If surgery is
necessary, treat until fusion. If anterior metal ware is placed (i.e. into the
infected field) long term therapy is considered.
iv) Oral step down
This is often required. See general comments above under principles of
management (section 2)
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e) Surgical management
The indications for surgery are persistent pain, recurrent infection, instability,
progressive deformity or neurological compromise.
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4. Spinal Epidural Abscess
a) Clinical features
Back pain, fever & progressive neurology, often from radicular pain to focal
weakness to paraparesis/paraplegia.
b) Diagnosis
Blood cultures (if febrile)
FBC, ESR, U&Es, LFTs, CRP
MRI of spine (urgent)
c) Goal setting
As for previous
d) Medical management
Acute spinal epidural abscess is an emergency. Patients are frequently bacteraemic.
Without prompt treatment, they can progress rapidly to spinal cord infarction
and/or death. Empirical IV antibiotics should therefore be started once blood
cultures have been obtained. Obtain urgent senior medical and orthopaedic input
and urgent MRI scanning.
i) Empirical IV Antibiotics
As above for vertebral osteomyelitis (i.e. teicoplanin and ciprofloxacin)
ii) Culture dependent IV antibiotics
For choice of drugs see general comments previously under principles of
management (section 2)
iii) Duration of treatment
Usually 6 weeks of intravenous therapy followed by three to six months of oral
antibiotic treatment. See general comments previously under principles of
management (section 2).
e) Surgical management
Surgery will usually be necessary.
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5. Spinal Implant Infection
a) Clinical features
As previous.
b) Diagnosis
FBC, ESR, U&Es, LFTs, CRP
For acute infection, ultrasound may be useful to look for collections
X-ray for evidence of loosening and to assess fusion of graft.
c) Goal setting
The goal of treatment is to keep the spine stable and eradicate infection if possible.
d) Medical management
Acute infections are treated as for acute prosthetic joint infections.
i) Empirical antibiotics
As previous.
ii) Culture dependent IV. antibiotics
For choice of drugs see general comments above under principles of
management (section 2).
iii) Duration of treatment
Current protocols for acute infection are for six weeks of intravenous therapy
followed by long term oral suppression until the implant is removed. Chronic
infections only require prolonged therapy if an aggressive pathogen is isolated
(treat as vertebral osteomyelitis). Most chronic infections of spinal metal are
with coagulase-negative staphylococci and Propionibacterium spp., and can be
treated with one week of intravenous antibiotics.
Teicoplanin 1.2g loading dose then 800mg OD IV
Followed by 3 weeks of oral therapy (see below)
iv) Oral step down
Long term oral therapy is required following an acute infection until the implant
is removed. For chronic infections after removal of metal work: three weeks of
oral clindamycin or amoxicillin (or other) according to sensitivity profile.
e) Surgical management
Orthopaedic Surgeons must be involved for debridement in acute infections and
removal of metalware in chronic infections.
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6. Acute Osteomyelitis
a) Clinical features
Fever and systemic upset. Pain, tenderness over bone
b) Diagnosis
Blood cultures
FBC, ESR, U&Es, LFTs, CRP
Biochemistry
X-ray of affected limb to exclude fracture
Consider ultrasound with aspiration for culture if subperiosteal collection
seen
MRI (confirmatory) or bone scan may be useful to confirm the diagnosis but
treatment should not usually be delayed awaiting the outcome of such tests.
c) Goal setting
The goal of treatment is to cure the acute infection and preserve healthy, living
bone. Early identification of failure to achieve this is important as medical and
surgical plans would be altered.
d) Medical management
Acute osteomyelitis is an emergency. The patients are often bacteraemic.
Furthermore, prompt treatment can prevent death of bone and progression to
chronicity. Therefore treat with intravenous antibiotics following blood cultures.
i) Empirical antibiotics
As previous
ii) Culture dependent IV antibiotics
For choice of drugs see general comments above under principles of
management (section 2).
iii) Duration of treatment
Four to six weeks, commonly given intravenously though there is experience in
children of transferring early to oral agents where recovery has been
uncomplicated. Longer durations of intravenous therapy may be necessary if,
despite an acute presentation, it has been necessary to drain abscesses and
remove dead bone.
iv) Oral step down
Rarely required unless there is evidence of chronic infection.
e) Surgical management
Orthopaedic Surgeons must be involved and will sometimes operate. However acute
osteomyelitis can be treated without surgery provided it is diagnosed and treated
sufficiently early to prevent the death of bone or the formation of abscesses.
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7. Acute Septic Arthritis (Native Joint)
a) Clinical features
Include fever, pain and monoarticular joint swelling. The patient is usually
systemically unwell. Remember that septic arthritis can be a presenting feature of
endocarditis.
b) Diagnosis
Blood cultures (before starting treatment)
FBC, ESR, U&E, LFTs, CRP
Aspiration of joint for gram stain and culture as well as crystals – if initial tap
is dry then it should be repeated under ultrasound control. Fluid should be
placed in sterile universal containers
X-ray the affected joint
In culture negative cases consider Brucellosis, Lyme disease or gonorrhoea
c) Goal setting
The aim is to preserve healthy bone and full function. Prompt treatment will
minimise the risk of subsequent joint destruction. Acute native joint septic arthritis is
an emergency.
d) Medical management
i) Empirical antibiotics
As previous
ii) Culture dependent IV antibiotics
For choice of drugs see general comments above under principles of
management (section 2).
iii) Duration of treatment and oral step-down
Duration of treatment is usually 2 to 4 weeks, but depends on clinical progress
and the infecting organism. It may be reasonable to consider step-down to oral
therapy once the patient has undergone appropriate surgical intervention, is
clinically stable and improving, and when appropriate oral agents are available
based on culture and sensitivity results. Oral step-down should be discussed
with Microbiology. When clinical progress is slow, consider re-imaging to look
for dead bone or foreign material.
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e) Surgical management
Orthopaedic Surgeons must be involved and will frequently have performed the first
stages of investigation and management. This will usually involve arthroscopic
washout or formal drainage (in the case of some joints e.g. hip). Beware of dead
bone, especially following hip infection. There is a risk of avascular necrosis and in
this case further careful exploration and removal of dead material is essential.
f)
Interdisciplinary issues
PICC line
Home IV team
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8. Acute Prosthetic Joint Infection
a) Clinical features
Acute prosthetic joint infections may occur early in the post-operative period or later
due to haematogenous spread to the artificial joint. Acute infections presenting late
are usually associated with a healed wound, and there is a higher incidence of
bacteraemia. They are characterised by sudden onset, and the fact that patients are
often unwell with local and systemic symptoms. Most centres take symptoms of
fever, pain and local inflammation of less than 2 weeks duration to indicate acute
infection.
b) Diagnosis
Blood cultures
FBC, ESR, U&E, LFTs, CRP
X-ray – loosening is not a feature
Aspiration of joint or collections, often ultrasound guided if post-operative.
Wound swab is of no diagnostic value but may be useful in excluding MRSA
colonisation.
c) Goal setting
The aim is to debride and retain the prosthetic joint
d) Medical management
Note the mainstay of treatment is surgical and medics should try to hold off
treatment until samples are obtained, unless the patient is septic.
i) Empirical antibiotics
These are not recommended before surgery unless there are clinical concerns
about septicaemia or the state of soft tissues. After surgery or if pre-operative
empirical antibiotics are indicated then the recommendation is for:
Teicoplanin 1.2g loading dose then 800mg OD IV
+
Ciprofloxacin 750 mg BD PO
(Unless the patient is nil by mouth or major problems with vomiting/oral
absorption are encountered or anticipated. NB IV dose is not equivalent to
oral dose).
ii) Culture dependent IV antibiotics
For choice of drugs see general comments above under principles of
management (section 2).
iii) Duration of treatment
6 weeks of intravenous antibiotics. After sampling stop ciprofloxacin after 48
hours if gram negatives are not isolated in cultures. Continue teicoplanin until
cultures available.
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iv) Oral step down
Long term oral therapy may be required for up to 6 months 5,6,7, 13. Discuss with
Microbiology or ID.
e) Surgical management
Debridement and retention. Multiple samples should be sent to Microbiology and
Histology2. Washout alone is considered insufficient. If there is evidence of
prosthetic instability or extensive infection in surrounding soft tissue then the
prosthesis should be removed
f)
Interdisciplinary issues
PICC line
Home IV team
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9. Chronic Prosthetic Joint Infection
a) Clinical features
Pain, especially “start up” suggesting loosening, malaise, anaemia of chronic disease
and wound drainage. Sinus formation is pathognomonic of underlying infection
b) Diagnosis
Blood cultures
FBC, ESR, U&Es, LFTs, CRP
X-ray of prosthetic joint
Aspiration arthrogram and/or biopsy. Joint fluid aspirates should
be sent in sterile universal containers, and if possible paediatric blood culture
bottles should also be inoculated at the same time
Bone Scan (very rarely indicated)
CT/MRI (very rarely indicated)
c) Goal setting
The goal of treatment is to provide a functional, pain-free joint, and not necessarily
cure. Some patients who are poor operative candidates may prefer to put a stoma
bag over a stable sinus and not proceed to operation.
d) Medical management
Chronic prosthetic joint infection is a stable condition. Treat with intravenous
antibiotics only following surgical debridement and multiple sampling. Where
suppression is attempted, protocols are as for acute prosthetic joint infection.
i) Empirical antibiotics (to be given after intra-operative
sampling)
1st stage of revision arthroplasty:
Teicoplanin 1.2g loading dose then 800mg OD IV
+
Ciprofloxacin 750 mg BD PO
(Unless the patient is nil by mouth or major problems with vomiting/oral
absorption are encountered or anticipated. NB IV dose is not equivalent
to oral dose).
2nd stage of revision arthroplasty:
Teicoplanin 1.2g loading dose then 800mg OD IV
+
Ciprofloxacin 750 mg BD PO
(Unless the patient is nil by mouth or major problems with vomiting/oral
absorption are encountered or anticipated. NB IV dose is not equivalent to
oral dose).
ii) Culture dependent IV antibiotics
For choice of drugs see general comments above under principles of
management (section 2).
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iii) Duration of treatment
Usually six weeks intravenous antibiotics after the first stage of the revision. This
is followed by two to three weeks free from antibiotic therapy before the second
stage, which should be covered with a stat dose of IV antibiotics as prophylaxis
after sampling at operation. Further doses are usually not required.
iv) Oral step down
Rarely required for gram positive organisms unless there is evidence of
osteomyelitis at the first stage revision. Gram negative infections are usually
treated for a further 6 weeks after intravenous therapy stops with a suitable oral
antibiotic (guided by sensitivities).
e) Surgical management
Surgical excision is generally necessary and some cases are only diagnosed after
excision arthroplasty. A small number of chronic infections are treated with implant
retention and long-term suppression. In such cases debridement or percutaneous
aspiration can define the causative organisms.
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10. Chronic Long Bone Osteomyelitis (Not diabetic foot)
a) Clinical Features
Pain is the predominant feature. There is long-standing infection evolving over
months or years, with relapses of fever, low grade inflammation and the presence of
dead bone8,9,10
b) Diagnosis
FBC, ESR, U &Es, LFTs, CRP
X-ray of affected bone
MRI
c) Goal setting
The goal of treatment is to cure the infection and preserve healthy, living bone.
d) Medical Management
Chronic osteomyelitis is a stable condition and empirical therapy should not be
commenced until after surgery.
i) Empiricial IV. antibiotics
Cefuroxime 1.5 g TDS IV if resistant organisms are not expected
Or, if resistant organisms or nosocomial infection are suspected.
Teicoplanin 1.2g loading dose then 800mg OD IV
+
Ciprofloxacin 750 mg BD PO
(Unless the patient is nil by mouth or major problems with vomiting/oral
absorption are encountered or anticipated. NB IV dose is not equivalent
to oral dose).
ii) Culture dependent IV antibiotics
Treatment should be rationalised once culture results are available.
Ciprofloxacin should be stopped after 48 hours if no gram negative organisms
are isolated. For choice of drugs see general comments above under principles
of management (section 2).
iii) Duration of treatment
For incomplete or uncertain excision six weeks of intravenous treatment is
recommended although this can be shorter if the infected bone has been
completely excised, dependent on microbiology and host status.
iv) Oral step down
Six weeks to three months1.
e) Surgical Management
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Orthopaedic Surgeons must be involved for debridement and multiple samples
should be sent to Bacteriology. Plastic surgery may be required for soft tissue cover.
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11. Diabetic Foot Infection excluding osteomyelitis
a)
Assessment:
Examination should include overall assessment of the patient’s status (for
example, whether there is evidence of systemic response to infection), and of
the limb rather than just the wound alone.
Urgent surgical referral should be considered if there is evidence of life- or
limb-threatening infection, or in patients with critical ischaemia.
Consider plain X-rays +/- MRI to look for evidence of underlying bone
infection.
b)
Surgical involvement:
- Surgical consultation regarding debridement, amputation or revascularisation
procedures should be considered.
c)
Antibiotic treatment:
Patients with clinically uninfected ulcers should not be treated with antibiotics.
Most likely infecting organism(s) depends on factors such as presence or absence of
ulceration, chronicity, local ischaemia or necrosis, and prior antibiotic exposure.
Chronically infected ulcers are more likely to be polymicrobial.
Appropriate microbiological samples should be obtained before antibiotic treatment
is commenced unless the patient is systemically unwell due to infection. In mild and
previously untreated cases, empirical treatment may be appropriate without
sampling. Samples obtained by biopsy, curettage or aspiration are preferable to
wound swabs.
Initial choice of antibiotic regimen should take into account a severity assessment
(see Table 1) and any available microbiological data such as past culture results.
Continue treatment until there is evidence that the infection has resolved, but not
necessarily until wound has healed. Treatment durations are given as a guide only,
and will depend on individual factors such as adequacy of surgical debridement and
clinical response to treatment. Early IV to oral switch will often be appropriate.
d)
Other considerations:
Glycaemic control is important, and close liaison with diabetes services is
advisable.
A wound-care plan to offload pressure from the wound encourage healing
should be formulated.
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Table 1. Diabetic foot severity assessment
Clinical manifestations
Severity
Suggested empirical antibiotics
(adapt if necessary based on
microbiology results / recent
antibiotic treatment)
Suggested duration
Uninfected
No antibiotic treatment
-
Presence of ≥2 of purulence/
erythema/pain/tenderness/w
armth/ induration, but
cellulitis extends ≤2cm, only
skin/superficial soft tissues
involved, no local
complications, not
systemically unwell
Mild
Clindamycin 450mg QDS PO
1-2 weeks
Infection as above and
systemically well but cellulitis
extends >2cm, lymphangitis,
spread beyond superficial
fascia, gangrene, involvement
of muscle/tendon/joint/ bone
Moderate
Co-amoxiclav 625mg TDS PO
2-4 weeks (see diabetic
foot infection including
osteomyelitis)
No purulence or
manifestations of
inflammation
In penicillin allergy:
Clindamycin 450mg QDS PO
and
Ciprofloxacin 750mg BD PO
For more extensive infection
consider:
Teicoplanin 1.2g stat, then
800mg OD IV
and
Ciprofloxacin 750mg BD PO
Systemic toxicity or metabolic
instability
Severe
Teicoplanin 1.2g stat, then
800mg OD IV
and
Ciprofloxacin 750mg BD PO
and
Metronidazole 400mg TDS PO
2-4 weeks
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12. Diabetic Foot Infection including osteomyelitis/septic arthritis
Consider possible osteomyelitis as a complication of any deep or extensive ulcer, particularly
if chronic and overlying a bony prominence, or if the ulcer fails to heal despite apparently
appropriate measures. If bone is visible or can be palpated with a blunt probe then
osteomyelitis is likely.
Swelling of the foot or a toe associated with a history of ulceration, and unexplained
elevation of inflammatory markers, should also arouse suspicion of osteomyelitis.
a)
Clinical Features
Osteomyelitis and Charcot’s arthropathy are limb threatening complications of
diabetes with very different therapies. Distinguishing between them is important. In
Charcot arthropathy non-infectious soft tissue inflammation accompanies rapidly
progressive destruction of joints then bone. This occurs in a well vascularised,
severely neuropathic but non-ulcerated joint. In osteomyelitis chronic soft tissue
infection precedes bone infection, which may be physically exposed 13.
b) Diagnosis
FBC, ESR, U&Es, LFTs, CRP, Hba1c
Plain X-ray of affected bone may suffice
MRI may be considered but is often not necessary
Bone biopsy is recommended if diagnosis remains in doubt after imaging, or
if the pathogen is unknown
c) Goal setting
The goal of treatment is to stop progressive damage to the foot and preserve pain
free function as far as possible.
d)
Surgical Management
Orthopaedic Surgeons must be involved for consideration of debridement
Multiple samples should be sent for culture & sensitivity.
Plastic surgery may be required for soft tissue cover.
Vascular surgery may be required for chronic ischaemia
e)
Medical Management
Chronic osteomyelitis is a stable condition and empirical therapy should preferably
not be commenced until after surgery or biopsy. Medical management without
surgery might be considered if:
There is no acceptable surgical target (i.e. surgery would have to be so radical
that it would result in unacceptable loss of function)
Surgery would carry excessive risk
Infection is confined to forefoot with minimal soft-tissue loss
i) Empiricial IV antibiotics
If resistant organisms are not expected:
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Cefuroxime 1.5g TDS IV
If resistant organisms or nosocomial infection are suspected:
Teicoplanin 1.2g loading dose then 800mg OD IV
+
Ciprofloxacin 750 mg BD PO
(Unless the patient is nil by mouth or major problems with vomiting/oral
absorption are encountered or anticipated. NB IV dose is not equivalent
to oral dose).
ii) Culture dependent antibiotic treatment
Treatment should be rationalised once culture results are available. Ciprofloxacin
should be stopped after 48 hours if no gram negative organisms are growing. For
choice of drugs see general comments above under principles of management
(Section 2).
iii) Duration of treatment
For incomplete or uncertain excision six weeks’ treatment is recommended.
Shorter treatment duration may be adequate if the infected bone has been
completely excised.
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13. Associated documentation and references
1. Lazzarini L, Lipsky BA, Mader JT. Antibiotic treatment of osteomyelitis: what have we
learned from 30 years of clinical trials? Int J Infect.Dis. 2005;9(3):127-38.
2. Atkins BL, Athanasou N, Deeks JJ, Crook DW, Simpson H, Peto TE et al. Prospective
evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at
revision arthroplasty. The OSIRIS Collaborative Study Group. J Clin.Microbiol.
1998;36(10):2932-9.
3. Conlon CP, Kayley J, Lalloo DG, Berendt AR. Intravenous antibiotic treatment at home
can provide higher quality care. BMJ 1997;314(7093):1551.
4. Ross JJ. Septic arthritis. Infect.Dis.Clin.North Am. 2005;19(4):799-817.
5. Sia IG, Berbari EF, Karchmer AW. Prosthetic joint infections. Infect.Dis.Clin.North Am.
2005;19(4):885-914.
6. Stengel D, Bauwens K, Sehouli J, Ekkernkamp A, Porzsolt F. Systematic review and
meta-analysis of antibiotic therapy for bone and joint infections. Lancet Infect.Dis.
2001;1(3):175-88.
7. Berendt AR, McLardy-Smith P. Prosthetic Joint Infection. Curr.Infect.Dis.Rep.
1999;1(3):267-72.
8. Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004;364(9431):369-79
9. Lazzarini L, Mader JT, Calhoun JH. Osteomyelitis in long bones. J Bone Joint Surg.Am.
2004;86-A(10):2305-18.
10. Calhoun JH, Manring MM. Adult osteomyelitis. Infect.Dis.Clin.North Am.
2005;19(4):765-86.
11. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW et al.
Diagnosis and treatment of diabetic foot infections. Plast.Reconstr.Surg. 2006;117(7
Suppl):212S-38S.
12. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW et al.
Diagnosis and treatment of diabetic foot infections. Clin.Infect.Dis. 2004;39(7):885910.
13. Byren I, Bejon P, Atkins BL et al One hundred and twelve infected arthroplasties
treated with ‘DAIR’ (debridement, antibiotics and implant retention): antibiotic
duration and outcome Journal of Antimicrobial Chemotherapy (2009) 63, 1264–1271
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Table 2. Organism specific antibiotic treatment
Notes: please, always check reported sensitivities on the antibiogram. For mixed infection Microbiology and Infectious Disease review is advisable.
Insert midline/PICC line insertion if envisaged length of IV therapy is > 1 week
Hospital treatment
Community IV
treatment
(IV Home therapy)
Choice if sensitive (usually
IV at this stage)
Streptococci
GAS, GBS, GGS, GGS
Benzylpenicillin 1.8g/6h
Oral choices
(e.g. stepdown stage or
temporary lack of IV line.
Microbiology and
Infectiouse Diseases review
advisable)
Alternative (drug allergy or
contraindication)
Ceftriaxone 2g OD
Ceftriaxone 2g OD
Clindamycin
Ciprofloxacin and
Rifampicin
or
Teicoplanin 1.2 g loading dose
then 800mg OD. Then three
times weekly post discharge to
home IV team (clindamycin if
sensitive)
MSSA
Flucloxacillin 2g/6h IV
Ceftriaxone 2g OD
Ceftriaxone 2g OD
plus
or
or
Rifampicin 300-600 mg BD Teicoplanin 1.2g loading dose
then 800mg OD
Plus
Rifampicin 300-600 mg BD
Teicoplanin 1.2 g loading
dose then 800mg OD.
Then three times weekly
post discharge to home IV
team
Clindamycin
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Comments
156
MRSA
MR-CNS
Teicoplanin 1.2 g loading
Teicoplanin 1.2 g loading
Linezolid 600mg BD
dose then 800mg OD. Then
dose then 800mg OD.
Contact med micro for approval Then three times weekly
three times weekly post
post discharge to home IV
discharge to home IV team
team
Ciprofloxacin and
Rifampicin (if sensitive)
Clindamycin (if sensitiveerythromycin)
Doxycycline/Trimethoprim
and Rifampicin
Enterococci
Teicoplanin 1.2 g loading
Amoxicillin 2g/4h
dose then 800mg OD. Then
three times weekly post
discharge to home IV team
E.coli
Klebsiella
Proteus
Ceftriaxone 2g OD
Meropenen 500mg/8h
ESBL
E.coli/Klebsiella/Proteus
Enterobacter
Serratia/Morganella
/Citrobacter/
Acinetobacter
Pseudomonas
Meropenem 500mg/8h
Ceftazidime 2g/8h
Teicoplanin 1.2 g loading Amoxicillin
dose then 800mg OD.
Then three times weekly
post discharge to home IV
team
Ciprofloxacin 750mg BD (if
sensitive)
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If Prosthetic material in
place, addition of
rifampicin advisable
157
Table 3. Summary of Recommended Empirical Antibiotic Therapy for Bone and Joint Infections
Indication
Vertebral
osteomyelitis &
discitis
Recommended empirical antibiotic therapy
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
Suggested duration
Usually six weeks of IV therapy followed by oral. If surgery
is necessary, treat until fusion. If anterior metal ware is
placed (i.e. into the infected field) long term therapy is
considered.
Oral step down often required.
Spinal epidural
abscess
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
Usually six weeks of IV therapy followed by three-six
months of oral therapy
Spinal implant
infection
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
Current protocols for acute infection are for six weeks of
IV therapy followed by long term oral suppression until
the implant is removed.
In the event of major wound contamination:
Teicoplanin 1.2g loading dose then 800mg OD IV
and meropenem 1g TDS IV
Chronic infections only require prolonged therapy if an
aggressive pathogen is isolated (treat as vertebral
osteomyelitis). Most chronic infections of spinal metal are
with coagulase-negative staphylococci and
Propionibacterium spp., and can be treated with one week
of IV antibiotics.
Long term oral therapy is required following an acute
infection until the implant is removed. For chronic
infections after removal of metal work: three weeks of
oral clindamycin or amoxicillin (or other) according to
sensitivity profile.
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Acute osteomyelitis
For community acquired infections:
Cefuroxime 1.5g TDS IV
For all patients with a previous history of trauma,
surgery or intravenous catheterisation; nosocomial
infections should be covered empirically with:
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
In the event of major wound contamination:
Teicoplanin 1.2g loading dose then 800mg OD IV
and meropenem 1g TDS IV
Acute septic arthritis
For community acquired infections:
Cefuroxime 1.5g TDS IV
For all patients with a previous history of trauma,
surgery or intravenous catheterisation; nosocomial
infections should be covered empirically with:
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
Four to six weeks, commonly given IV though there is
experience in children of transferring early to oral agents
where recovery has been uncomplicated. Longer
durations of IV therapy may be necessary if, despite an
acute presentation, it has been necessary to drain
abscesses and remove dead bone. If gentamicin is to be
continued advice should be sought from Microbiology
and/or Pharmacy with regards to dosage and monitoring.
Oral step down rarely required unless there is evidence of
chronic infection.
Duration of treatment is usually two to four weeks, but
depends on clinical progress and the infecting organism. It
may be reasonable to consider step down to oral therapy
once the patient has undergone appropriate surgical
intervention, is clinically stable and improving, and when
appropriate oral agents are available based on culture and
sensitivity results. When clinical progress is slow, consider
re-imaging to look for dead bone or foreign material.
In the event of major wound contamination:
Teicoplanin 1.2g loading dose then 800mg OD IV
and meropenem 1g TDS IV
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Acute prosthetic joint
infection
These are not recommended before surgery unless
there are clinical concerns about septicaemia or
the state of soft tissues. After surgery or if preoperative empirical antibiotics are indicated then
the recommendation is for:
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
Chronic prosthetic
joint infection
Empirical antibiotics (to be given after intraoperative sampling)
1st stage of revision arthroplasty:
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
2nd stage of revision arthroplasty:
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
Chronic long bone
osteomyelitis (not
diabetic foot)
If resistant organisms are not expected:
Cefuroxime 1.5g TDS IV
If resistant organisms or nosocomial infections
should be covered empirically with:
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
Six weeks of IV antibiotics. After sampling stop
ciprofloxacin after 48 hours if gram negatives are not
isolated in cultures. Continue teicoplanin until cultures
available.
Long term oral therapy may be required for up to six
months.
Usually six weeks intravenous antibiotics after the first
stage of the revision. This is followed by two to three
weeks free from antibiotic therapy before the second
stage, which should be covered with a stat dose of IV
antibiotics as prophylaxis after sampling at operation.
Further doses are usually not required.
Oral step down rarely required for gram positive
organisms unless there is evidence of osteomyelitis at the
first stage revision. Gram negative infections are usually
treated for a further six weeks after IV therapy stops with
a suitable oral antibiotic (guided by sensitivities).
Treatment should be rationalised once culture results are
available. Ciprofloxacin should be stopped after 48 hours if
no gram negative organisms are isolated.
For incomplete or uncertain excision six weeks of IV
treatment is recommended although this can be shorter if
the infected bone has been completely excised,
dependent on microbiology and host status.
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Oral step down may be required for between six weeks
and three months.
Diabetic foot
If resistant organisms are not expected:
infection (including
Cefuroxime 1.5g TDS IV
osteomyelitis & septic
arthritis)
If resistant organisms or nosocomial infections
should be covered empirically with:
For incomplete or uncertain excision six weeks treatment
is recommended. Shorter treatment duration may be
adequate if the infected bone has been completely
excised.
Teicoplanin 1.2g loading dose then 800mg OD IV
and ciprofloxacin 750mg BD PO
Diabetic foot
infection (excluding
osteomyelitis)
Patients with clinically uninfected ulcers should not
be treated with antibiotics. Most likely infecting
organism(s) depends on factors such as presence
or absence of ulceration, chronicity, local
ischaemia or necrosis, and prior antibiotic
exposure. Chronically infected ulcers are more
likely to be polymicrobial.
Treatment durations are given as a guide only, and will
depend on individual factors such as adequacy of surgical
debridement and clinical response to treatment. Early IV
to oral switch will often be appropriate.
Appropriate microbiological samples should be
obtained before antibiotic treatment is
commenced unless the patient is systemically
unwell due to infection. In mild and previously
untreated cases, empirical treatment may be
appropriate without sampling. Samples obtained
by biopsy, curettage or aspiration are preferable to
wound swabs.
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Initial choice of antibiotic regimen should take into
account a severity assessment and any available
microbiological data such as past culture results
(see table 2). Continue treatment until there is
evidence that the infection has resolved, but not
necessarily until wound has healed.
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162
The Royal Liverpool and Broadgreen
University Hospitals
Appendix 6
INITIAL MANAGEMENT OF SEPSIS
Hosp No
Name
Address
PLEASE NOTE:
Patients who are systemically well may not require
urgent empirical antibiotic treatment
EXCEPT immunocompromised / haematology / oncology patients
STEP 1: DIAGNOSIS – SYSTEMIC INFLAMMATORY REACTION
TWO or more of the following:
o
o
o
o
o
Temperature
Tachycardia
Tachypnoea
WCC
o
>38 C or <36 C
>90bpm
RR >20/min or PaC02 <4.26 kPa
3
<4 or >12/mm
If yes, patient has SIRS
move to step 2
STEP 2: RISK STRATIFICATION
A. SEPSIS: (mortality 16%)
If yes, patient has sepsis
SIRS with Infection
move to step 3
Urgent antibiotic (within 1 hour) in
B. SEVERE SEPSIS: (mortality 36%)
Sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion
If yes, patient has severe sepsis
ANY of the following if assumed secondary to infection:
o Hypoxia
PaO2 / FiO2 <40 (ALI) or <26 (ARDS)
o Hypotension
SBP <90mm Hg or fall of >40mm Hg
o Acute Kidney Injury
creatinine > 177 mmol/L or
Acute oliguria
<0.5ml/kg/hr for 2 hours
o Raised lactate
>2mmol/l
o Platelets
< 100
o Coagulopathy
INR >1.5 or APTT >60s
o Bilirubin
>70µmol/l
o Acute confusion / altered mental state
C: SEPTIC SHOCK: (mortality 46%)
page 5021/ext 3686
page 4980
page 4502
page 4016
via switch
If lactate > 4 consider contacting
critical care immediately
If yes, patient has septic shock
Severe sepsis plus hypotension not reversed by optimal fluid
resuscitation
Useful contacts
Acute oncology team
AMU antimicrobial pharmacist
Antibiotic pharmacist
CCOT (0800 to 1900)
Haematology SpR
move to step 3
AND
contact senior doctor
move to step 3 AND
Haematology out-of-hours nurse
Infectious Diseases SpR
ITU on call
Medicines information
Microbiology
Management of sepsis / Folb / Shek / Version 1.6 / July 2011
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ext 2476 (7Y)
page 4578
page 4513 / ext 2400
ext 2096
page 4415/ext 4410
163
STEP 3: IMMEDIATE MANAGEMENT
Time / source
A. OXYGEN THERAPY
Supplemental oxygen therapy to achieve minimum PaO2 of 8.0kPa
B. FLUID RESUSCITATION
Resuscitate immediately in patients with hypotension or serum lactate >4 mmol/L
Hartmann’s solution 500ml / 30 min to maintain systolic BP >90mmHg, repeat up to 4 times
If further fluid resuscitation required contact senior doctor
C. MICROBIOLOGICAL CULTURES
Obtain blood cultures before starting antibiotics: obtain ≥2 BC sets AND if intravascular
device present for ≥48h, send blood cultures from each lumen
Culture from other sites - before antibiotics, provided this does not significantly delay
treatment (e.g. CSF, sputum, urine, pleural or ascitic fluid, joint aspirate, throat /wound /
HVS swab)
D. IMAGING STUDIES
Imaging studies to confirm source of infection if safe to do so
Tick
Time
Source
E.
SOURCE IDENTIFICATION AND CONTROL
Assess patient for focus amenable to source control measures (e.g. abscess drainage, tissue
debridement, joint washout, laparotomy, removal of foreign device)
Involve surgical or orthopaedic team early as appropriate
Remove intravascular devices if potentially infected (send line tip for culture)
Enquire about travel history and assess malaria risk
F. ANTIBIOTIC THERAPY
Antibiotic choice for patients with a focus of infection should be guided by trust antibiotic policy
Previous microbiology results may help guide antibiotic choice
Commence IV antibiotics within 1hr of recognising severe sepsis or neutropenic sepsis
Name
Most likely septic focus
Designation
First Line
Prescribed
Given
Signature
Second line (penicillin allergy)
IV tigecycline 100mg stat, then
50mg bd AND
IV gentamicin stat
IV teicoplanin AND
IV clarithromycin 500mg bd
Date
Other considerations
Biliary tract /
other intra-abdominal infection
IV piperacillin/tazobactam 4.5g tds
+/- IV gentamicin stat
Community acquired pneumonia
(CURB – 3 or more)
IV benzylpenicillin 2.4g qds AND
IV clarithromycin 500mg bd
Spreading cellulitis
IV flucloxacillin 1g qds AND
IV benzylpenicllin 1.8g qds
IV teicoplanin
Epiglottitis
IV ceftriaxone 2g bd
Contact medical microbiology
Meningitis
IV ceftriaxone 2g bd
IV chloramphenicol 1g qds
Add aciclovir 10mg/kg tds if evidence of encephalitis, add
IV amoxicillin 2g qds if immunocompromised or aged >55
Necrotising fasciitis
IV meropenem 1g tds AND
IV clindamycin 900mg tds
Contact medical microbiology
Arrange urgent senior surgical review & intervention
Neutropenic sepsis
IV piperacillin/tazobactam 4.5g tds
+/-IV gentamicin stat
Sepsis of unknown origin
IV piperacillin/tazobactam 4.5g tds
+/- IV gentamicin stat
Septic arthritis / osteomyelitis
If community acquired
IV cefuroxime 1.5g tds AND
gentamicin stat
IV teicoplanin AND
PO ciprofloxacin 750mg bd
Urosepsis
IV piperacillin/tazobactam 4.5g tds
+/- IV gentamicin stat
PO ciprofloxacin 500mg BD
+/- IV gentamicin stat
Non-severe allergy IV
meropenem 1g tds.
Severe penicillin allergy
IV aztreonam 2g tds AND
gentamicin stat AND teicoplanin
IV teicoplanin AND
IV metronidazole 500mg tds AND
IV ciprofloxacin 400mg bd.
Consider Gentamicin stat dose in
addition
Consider urgent surgical review
SBP use IV piperacillin/tazobactam 4.5g tds
Consider sending urine for Legionella and pneumococcal
antigen, serum, viral nose and throat swabs
Consider possibility of necrotising fasciitis if severe
systemic upset; adjust therapy if known MRSA
colonisation; refer to Ab policy if history of bite
Include teicoplanin in presence of long term intravascular
device
Include teicoplanin in presence of long term intravascular
device
Arrange urgent orthopaedic review.
Use 2nd line regime if recent surgery or trauma.
Use teicoplanin AND meropenem if major wound
contamination
Gentamicin 5mg/kg (Max 450mg) Stat (levels 8-12 hours after 1st dose then follow antibiotic formulary appendix 1).
Use gentamicin calculator for advice on dosing.
Possible cautions and contra-indications to gentamicin therapy should be considered – refer to BNF
Teicoplanin 1.2g stat, then 800mg od (refer to antibiotic formulary appendix 2)
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Appendix 7
Penicillin
Allergy
164
Please endorse all prescription charts clearly with full details of the patients allergy
Review medical notes/previous drug charts and phone the GP if unsure about nature of the allergy
Discuss investigation & desensitisation with allergy or immunology clinician if penicillin must be used
Penicillin Containing Antibiotics
CONTRA-INDICATED
Amoxicillin
Ampicillin
Cefradine
Co-amoxiclav (Augmentin®)
Flucloxacillin
Benzylpenicillin (Penicillin G)
Phenoxymethylpenicillin (Penicillin V)
Piperacillin/tazobactam (Tazocin ®)
Other Beta-lactam Antibiotics
Crossover allergy possible (approximately 10%
overall but <5% with carbapenems).
Avoid if undefined or serious penicillin allergy (e.g.
anaphylaxis/angiodema).
Use with caution if non-severe allergy and no
alternative (e.g.macular papular rash).
Cefalosporins:
Cefuroxime
Cefotaxime
Ceftazidime
Ceftriaxone
Carbapenems:
Ertapenem*
Meropenem
Aztreonam
Imipenem
*Ertapenem is contraindicated in patients with severe
penicillin allergy e.g. anaphylaxis
Non Beta-lactam antibiotics
CONSIDERED SAFE
(Not an exhaustive list)
Amikacin
Azithromycin
Ciprofloxacin
Clarithromycin
Clindamycin
Co-trimoxazole
Doxycycline
Erythromycin
Gentamicin
Levofloxacin
The Royal Liverpool and Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-15
Metronidazole
Moxifloxacin
Nitrofurantoin
Ofloxacin
Oxytetracycline
Rifampicin
Sodium Fusidate
Teicoplanin
Tetracycline
Trimethoprim
165
Appendix 8
Guidelines for Antibiotic prophylaxis in relation to urinary bladder
catheterisation
Quick guide
Antibiotic prophylaxis indicated
Antibiotic prophylaxis NOT indicated
prosthetic joint / implant <6 weeks
Patients with risk factors for infective endocarditis
painless/chronic urinary retention
Patients with established prosthetic joints/ grafts / implants
removal of catheter following prostate surgery
Based on one of the following risk factors:
- history of symptomatic catheter-associated infection with
previous catheter changes, OR
- purulent urethral / suprapubic catheter site discharge, OR
- exit site colonisation with S aureus, OR
- multiple traumatic attempts to catheterise
painful / acute urinary retention
catheter insertion pre-surgery
catheter insertion for fluid monitoring
catheter insertion for incontinence
suprapubic catheter insertion
Summary of recommendations:
1.
Patients with urinary tract infections (UTI) who require catheter insertion should be started on antimicrobial treatment
prior to catheterisation wherever possible.
2.
Uncatheterised patients known to have asymptomatic bacteriuria who require catheter insertion should be given a dose of
antimicrobial prophylaxis prior to catheterisation according to susceptibilities of the urinary isolate.
3.
Catheterised patients with urinary tract infections should be commenced on empirical treatment prior to catheter changes
4.
Routine use of antimicrobial prophylaxis for urinary catheter insertion/change/removal solely for the prevention of
endocarditis is not recommended
5.
Routine use of antimicrobial prophylaxis for urinary catheter insertion/change/removal solely for the prevention of infection
of established prosthetic joints and other medical implants is not recommended
6.
Routine antimicrobial prophylaxis is not recommended for insertion of urinary catheters in patients with acute painful
urinary retention
7.
Routine antimicrobial prophylaxis is recommended for insertion of urinary catheters in patients with chronic painless
urinary retention
8.
A urine sample should be routinely collected for culture at the time
insertion. Urinary tract infection, if
confirmed, should be treated according to local guidelines and sensitivity results
9.
Routine antimicrobial prophylaxis is not recommended for insertion of short term urinary catheters pre-operatively
10. Routine antimicrobial prophylaxis is not recommended for insertion of short term urinary catheters for fluid monitoring or
incontinence management
11. Routine prophylaxis is recommended for insertion or removal of urinary catheters in the six weeks after joint replacement
surgery
12. Routine prophylaxis is recommended for catheter removal
surgery
13. Prophylaxis is not otherwise recommended for catheter removal, unless the urine or urethral meatus is known to be
colonised with Staphylococcus aureus (including MRSA)
14. Antimicrobial prophylaxis is not recommended at the time of initial
long term indwelling urinary catheters
or suprapubic catheters, provided there is NO clinical urinary tract infection OR known asymptomatic bacteriuria at
the time of insertion (from previous urine samples).
15. Prophylaxis is not recommended for routine catheter changes unless a patient has:
a.
a history of symptomatic urinary catheter-associated infection with previous catheter changes or purulent
urethral/suprapubic catheter exit site discharge AND/OR
b.
catheter or meatal/suprapubic
siteHospitals
colonisation
with Staphylococcus
aureus
The Royal Liverpool andcatheter
Broadgreen exit
University
NHS Trust: Antimicrobial
prescribing guidelines
2013-15 (including MRSA)
16. Prophylaxis may be considered following traumatic catheterisation or after multiple unsuccessful catheterisation attempts
17. Urinary catheters involved in urinary tract infection may need removal
166
Procedure
Prophylaxis recommended? Evidence
level
Prophylaxisaims to
reduce
Antimicrobial dose/route. Give iv/im
gentamicin <1 hour prior to catheter
manipulation
Routine
A. All catheter insertions/change/removal
i) In patients with
NO. But follow this
endocarditis risk factors guideline for other
indications.
-
-
D
-
-
i) insertion for painful
NO. But follow
(acute) urinary retention UTI guideline if
symptoms of UTI
B
-
-
ii) insertion for
painless
(chronic) urinary
retention
YES (send CSU after
catheterisation and treat if
confirmed UTI)
D
Bacteraemia
Gentamicin 120mg iv/im single dose
iii) insertion preoperation
NO. But catheterise
after any routine surgical
antimicrobial prophylaxis
has been given.
B
-
-
iv) insertion for fluid
monitoring,
incontinence
NO
B
-
-
v) insertion or
removal
<6 weeks
post joint
replacement
YES
D
Prosthesis
infection
Gentamicin 120mg iv/im single dose
vi) removal- post
prostatic
surgery
YES
D
UTI, bacteraemia *Gentamicin 120mg iv/im single dose
NO. Unless Staphylococcus
aureus in urine or meatal
sample
3
C. Long term catheterisation (>28 days)
D
Bacteraemia
*Gentamicin 120mg iv/im single dose
i) First time insertion
NO
B
-
-
ii) Suprapubic catheter
insertion
NO
D
-
-
iii) catheter
change/removal
Risk assess – see full
guideline.
3
B
Bacteraemia
*Gentamicin 120mg iv/im single dose
ii) In patients with
established
prosthetic joints,
vascular grafts and
other medical
implants
NO. As above. See also
B(v) for recent joint
surgery in previous 6
weeks.
B. Short term catheterisation (<28 days)
C
12
3
vii) removal- all
other indications
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167
Introduction
The aim of this guideline is to standardise the use of antimicrobial prophylaxis for urinary bladder
catheterisation.
A review of antimicrobial prophylaxis recommendations for urinary bladder catheterisation has been
prompted by:
a general lack of clarity in the organisation about the need (or not) for antimicrobials in this
situation and a desire for a standardised approach. The confusion in this area has been
highlighted by a recent audit of gentamicin prescribing in the Trust.
ongoing problems with Clostridium difficile infection in the Trust;
publication of endocarditis prophylaxis guidelines by NICE.
Urinary tract infection (UTI) accounts for about 40% of hospital-acquired (nosocomial) infections,
and about 80% of urinary tract infections acquired in hospital are associated with urinary catheters
4 5
. Between 5.7 and 9% of hospital-acquired bacteraemias are caused by urinary catheterassociated urinary tract infections (CA-UTI) 6 and attributable mortality has been reported to be
12.7% 7. Relative to the number of catheters inserted, secondary bacteraemia is an uncommon
complication occurring in <4% of patients with urinary catheter-associated bacteriuria 8.
Insertion of urethral catheters is a very common procedure, carried out in 11% of inpatients in one
European study 9 and has a variety of indications including: peri-operative urine collection,
management of urinary incontinence/retention and to measure urine output in acutely unwell
patients.
Many factors have been associated with catheter-associated urinary tract infections and there are
multiple approaches to reducing these infections. These guidelines are solely concerned with
systemic antimicrobial prophylaxis.
Where the recommendations in these guidelines do not seem appropriate for a particular patient,
discussion of the patient with a microbiologist is advised.
In this guideline, the term catheter manipulation refers to either insertion, removal or change of a
urinary catheter. This guideline does not cover patients who intermittently self-catheterise.
Background
There are relatively few studies of prophylaxis for routine catheter insertion. Most are not powered
to detect any statistically significant difference in the rates of infection. These guidelines
draw on national guidelines where available, a review of available evidence for specific areas of
concern/controversy, and local consensus.
There is considerable variation in the practise of prophylaxis for urethral catheter insertion in the UK
10
. Practice varies with patient group and between healthcare professionals 11. Gentamicin is
commonly used for insertion, change and removal; without a clear evidence base 10. The European
Association of Urology guidelines on urological infection have recommended against antimicrobial
prophylaxis for urinary catheter insertions. 12
Because urinary catheters are used in many different settings with different risks, a blanket
approach to systemic antimicrobial prophylaxis would result in many patients receiving
antimicrobials unnecessarily. These guidelines therefore deal with the common situations
separately. Where a situation is not covered by the guideline or clinical circumstances require a
different approach, discussion with microbiology is recommended.
* depending on susceptibility and vascular access – call microbiology if necessary
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As a general principle, the risk of bacteraemia associated with catheterisation depends on
prior urine colonisation or infection 13.
Notes on selection of appropriate agent for prophylaxis
In some instances, for example in patients known to have prior asymptomatic bacteriuria
who then undergo catheterisation, the choice of antibiotic agent should be based upon
known sensitivity results for the bacterial isolate. Otherwise, the choice of antimicrobial
agent for prophylaxis is based on spectrum of activity and renal excretion.
Gentamicin has broad anti-Gram-negative and anti-staphylococcal activity. It is excreted
primarily in the urine, has a low propensity to cause Clostridium diffiicle infection or MRSA
colonisation and is therefore an ideal agent for prophylaxis of UTI during catheter
manipulation. The disadvantages of gentamicin use are the requirement for parenteral
administration and a small (with single doses) risk of nephrotoxicity.
Part A: General recommendations
Recommendation: Patients with urinary tract infections (UTI) who require catheter
insertion should be started on antimicrobial treatment prior to catheterisation
wherever possible.
[Evidence level D]
Recommendation: Uncatheterised patients known to have asymptomatic
bacteriuria who require catheter insertion should be given a dose of antimicrobial
prophylaxis prior to catheterisation according to susceptibilities of the urinary
isolate.
[Evidence level D]
Recommendation: Catheterised patients with urinary tract infections should be
commenced on empirical treatment prior to catheter changes.
[Evidence level D]
Part B. Endocarditis, joint prostheses and other medical implants.
i) Recommendation: Routine use of antimicrobial prophylaxis for urinary
catheter insertion/change/removal solely for the prevention of endocarditis
is no longer recommended 2.
[Evidence level C]
NICE guidelines published in 2008 have recommended against routine endocarditis
prophylaxis for patients deemed to be at high risk of endocarditis who undergo urological
procedures (including catheter insertion). Urinary tract infections occurring in such patients
should be investigated and treated appropriately.
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ii) Recommendation: Routine use of antimicrobial prophylaxis for urinary catheter
insertion/change/removal solely for the prevention of infection of established
prosthetic joints and other medical implants is not recommended.
[Evidence level D]
Infections of established indwelling prostheses with urinary pathogens is a very rare
complication of catheter withdrawal and does not justify the risks associated with routine
prophylaxis 14 15.
Part B Short term urinary catheters
i) Recommendation: Routine antimicrobial prophylaxis is not recommended for
insertion of urinary catheters in patients with acute painful urinary retention.
[Evidence level B]
Acute painful urinary retention is not usually associated with urinary tract infection, and
prophylaxis is therefore not advised. One evidence-based review concluded that
prophylaxis could not be recommended in this situation. 16
A urine sample should be routinely collected for culture at the time of catheter insertion. If
microscopy and culture results suggest the presence of infection then appropriate antibiotic
treatment should be instituted based on sensitivity results. Urine samples collected at the
time of catheter insertion should be labeled “Midstream urine” (MSU) rather than “CSU”, so
that a white blood cell count is performed.
ii) Recommendation: Routine antimicrobial prophylaxis is recommended for insertion
of urinary catheters in patients with chronic painless urinary retention.
[Evidence level D]
Recommendation: A urine sample should be routinely collected for culture at the
time of catheter insertion; UTI, if confirmed, should be treated according to local
guidelines and sensitivity results. [Evidence level B]
Chronic painless urinary retention is associated with urinary tract infection in a high
proportion of cases. Therefore antimicrobial prophylaxis is advised for catheter insertion in
this setting. A urine sample should then be collected for culture at the time of catheterisation
and empirical treatment commenced for urinary tract infection if clinically appropriate.
iii) Recommendation: Routine antimicrobial prophylaxis is not recommended for
insertion of short term urinary catheters pre-operatively.
[Evidence level B]
A Cochrane review concluded that evidence for prophylactic antibiotics reducing the rate of
bacteriuria and signs of infection in patients with short term catheters, is weak 5. In a small
placebo controlled trial of ciprofloxacin prophylaxis for removal of short term urethral
catheters, there was no significant difference in rates of UTI between groups and
ciprofloxacin resistance was common among the causes of post-removal UTIs 17. A cost
effectiveness analysis did not recommend routine use of antimicrobial prophylaxis 18
Many procedures requiring urinary catheter insertion will also require antimicrobial
prophylaxis for surgical site infection. It is a pragmatic recommendation that urinary
catheters should be inserted after routine peri-operative prophylaxis has been given
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because there is a small risk of bacteriuria at the time of any catheter insertion and Gram
negative bacteria are a well recognised cause of surgical site infection. N.B Early work on
urological procedures revealed that bacteraemia rarely occurred when pre-operative urine
was sterile.
iv) Recommendation: Routine antimicrobial prophylaxis is not recommended for
insertion of short term urinary catheters for fluid monitoring or incontinence
management.
[Evidence level B]
A Cochrane review concluded that evidence for prophylactic antibiotics reducing the
rate of bacteriuria and signs of infection in patients with short term catheters, is
weak 5.
v) Recommendation: Routine prophylaxis is recommended for insertion or
removal of urinary catheters in the six weeks after joint replacement surgery.
[Evidence level D]
Gram negative bacilli are a well recognised cause of early prosthetic joint infection (PJI) but
a rare cause of late infections. Although the urinary tract is a potential source of these
early Gram negative infections, 19 a large case control study of risk factors for PJI did not
find a significant difference in either pre-operative pyuria or bacteriuria or post-operative
nosocomial urinary tract infection between 462 cases and matched controls 20. There is,
however, a local consensus among orthopaedic surgeons that gentamicin should be given
for catheter insertion, change or manipulation during the early post-operative phase. The
early post operative phase is (arbitrarily) defined as up to six weeks post surgery.
vi) Recommendation: Routine prophylaxis is recommended for catheter
removal following prostatic surgery.
In addition to single dose antimicrobial prophylaxis for prostatic surgery, it has been argued
that prophylaxis should be given to cover urethral catheter removal because of the well
described risk of bacteraemia. [Evidence level D]
vii) Recommendation: Prophylaxis is not otherwise recommended for catheter
removal, unless the urine or urethral meatus is known to be colonised with
Staphylococcus aureus (including MRSA). [Evidence level D]
The is no evidence to support the use of prophylactic antimicrobials for catheter removal.
However catheter removal does appear to be a risk factor for Staphylococcus aureus
bacteraemia in patients with urine known to be colonised with Staphylococcus aureus.
The pragmatic recommendation is to offer prophylaxis in this situation. (see also long
term catheterisation section for rationale).
Part C: Long term indwelling urinary catheters
i) Recommendation: Antimicrobial prophylaxis is not recommended at the time of
initial insertion of long term indwelling urinary catheters, provided there is NO
clinical evidence of urinary tract infection AND the patient is not known to have
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asymptomatic bacteriuria at the time of insertion. [Evidence level B]
Long-term urinary catheters inevitably become colonised with bacteria regardless of
antimicrobial prophylaxis at the time of insertion so prophylaxis offers no benefit. 18 21.
ii) Recommendation: Antimicrobial prophylaxis is not recommended at the time of
suprapubic urinary catheter insertion, provided there is no urinary tract infection at
the time of insertion. [Evidence level D]
iii) Recommendation: Prophylaxis is not recommended for routine catheter changes
unless a patient has:
A)
a history of symptomatic urinary catheter-associated infection with previous
catheter changes, AND/OR
B) purulent urethral/suprapubic catheter exit site discharge, AND/OR
C) catheter or meatal/suprapubic catheter exit site colonisation with
Staphylococcus aureus (including MRSA).
[Evidence level B,D]
NICE guidelines recommend that prophylaxis is not required for routine changes of
indwelling urethral catheters on the basis of low rates of infective complications
coupled with a lack of evidence that prophylaxis is effective 3.
There is a high likelihood of development of resistance associated with prophylaxis
strategies as illustrated by a study comparing norfloxacin and placebo in elderly nursing
home patients with indwelling urethral catheters 22. Although a significant reduction of
catheter-associated UTI was demonstrated, 25% of strains in placebo patients compared
with 90% of strains in norfloxacin patients were resistant to norfloxacin at the end of the
prophylaxis period, highlighting that any benefit of prophylaxis is likely to be short-lived
due to the development of resistance 22.
It is recommended that a risk assessment be undertaken based on previous history of
infections with catheter changes and local examination findings and urine or meatal culture
results. If a patient has had previous episodes of infection associated with changes, or has a
purulent meatal discharge, or urine/meatal swabs are positive for Staphylococcus aureus
(including MRSA), then prophylaxis is recommended according to the summary table below.
Part D Urinary tract infection.
iii) Urinary catheters involved in urinary tract infection may need removal
Acknowledgment
This policy was originally developed by a multidisciplinary group in Leeds, and has been
slightly modified for local use. The original authors have given permission for this, and their
work in developing the policy is gratefully acknowledged. They are: Dr Jonathan Sandoe, Mr
Ian Eardley, Mrs Abimbola Olusoga and Mrs Kathryn Brown.
The Royal Liverpool and Broadgreen University Hospitals NHS Trust: Antimicrobial prescribing guidelines 2013-15
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