1. PRINCIPALS OF GOOD ANTIBIOTIC PRESCRIBING
EMPIRICAL TREATMENT
SEPSIS
RESPIRATORY
RESPIRATORY (cont’d)
URINARY TRACT
Community Acquired Pneumonia (CAP) .
Severity of CAP criteria (CURB-65) - 1 point for each
C onfusion (new onset)
U rea > 7mmol/L
R espiratory rate ≥ 30/minute
B lood pressure (SBP < 90mmHg; DBP ≤ 60mmHg)
65 age ≥ 65 years
Mild CAP (CURB-65 score 0 - 1)
1st line: Amoxicillin 500mg PO TDS
Penicillin allergy: Clarithromycin 500mg PO BD
Total duration: 5-7 days
Moderate CAP (CURB-65 score 2)
1st line: Amoxicillin 500mg - 1g PO TDS
+ Clarithromycin 500mg PO BD
Total duration: 7-10 days
Severe CAP (CURB -65 score ≥ 3)
1st line: Co-amoxiclav 1.2g IV TDS + Clarithromycin 500mg PO/IV BD
Penicillin allergy: Teicoplanin 400mg IV BD for 3 doses then 400mg OD (depending on renal function) + Clarithromycin 500mg IV/PO BD
Contact Microbiology for further advice, especially if there is any history of immunosuppression, underlying respiratory disease or excess alcohol consumption
Test for legionella antigen (urine) in moderate and severe CAP
Infective exacerbation of COPD
1st line: Doxycycline 100mg PO BD for 7 days
If intolerant to tetracyclines , Amoxicillin can be used.
Hospital acquired pneumonia (HAP)
1st line: Co-amoxiclav 1.2g IV TDS
If known MRSA : Add Teicoplanin 400mg IV BD for 3 doses then 400mg OD (depending on renal function.)
Penicillin allergy: Teicoplanin 400mg IV BD for 3 doses, then 400mg IV OD
+ Gentamicin 3-5mg/kg IV OD
Contact Microbiology for further advice
Review treatment at 5 days – most do not require further antibiotic
Legionella Pneumonia (only if confirmed legionella)
Consider in HAP:
- Inpatient Living in an institution
- Recent hospital admission Travel History
1st line: Levofloxacin 500mg IV BD
NB check urinary antigen (rapid diagnostic test).
Positive contact microbiology
Negative consider stopping Levofloxacin
Community Acquired Aspiration pneumonia (If treatment is necessary):
Review diagnosis after 5 days. Many do NOT require further antibiotics.
1st line: Amoxicillin 500mg IV TDS
+ Metronidazole 500mg IV TDS
Penicillin allergy: Clarithromycin 500mg IV BD
Hospital Acquired Aspiration pneumonia
1st line: Amoxicillin 500mg IV TDS
+ Gentamicin 3-5mg/kg IV
Penicillin allergy:
Teicoplanin 400mg IV BD for 3 doses, then 400mg IV OD (depending on renal function) + Gentamicin 3-5mg/kg IV OD + Metronidazole 500mg IV TDS
PRINCIPALS OF GOOD ANTIBIOTIC PRESCRIBING
Uncomplicated, Lower UTI .
1st Line: Nitrofurantoin 100mg PO QDS for 3 days for women, 7 days for men
If GFR <45ml/min then choose from below
1st Line: Pivmecillinam PO
Body-weight 40 kg and above: Initially 400 mg for 1 dose, then 200 mg every 8 hours for 3 days for women, 7 days for men.
2nd Line: Gentamicin 3-5mg/kg IV OD ( see gentamicin guideline).
Complicated UTI, Pyelonephritis & Catheter associated UTI
1st Line: Gentamicin 3-5mg/kg IV OD (max dose: 480mg)
Review at 48 hours, streamline choice as per sensitivities , if necessary, seek Microbiology advice
Pyelonephritis – IV to Oral switch
Co-amoxiclav 625mg TDS for 14 days
Penicillin Allergy : Ciprofloxacin 500mg BD for 14 days
Start antibiotics within 1 hour for severe / life-threatening infections
Blood Cultures must be taken – Mandatory
Sepsis criteria See Sepsis Care pathway
Suspicion of infection AND 2 or more of the following:
• Temperature <36oC or >38oC • Respiratory rate >20 BPM
• Heart rate >90 BPM • WCC <4 or >12 x 109/L
Septicaemia (unknown source)
Severe systemic infection before results available – review antibiotics in hours.
Refer to surviving sepsis guideline
1st line: Co-amoxiclav 1.2g IV TDS
+ Gentamicin 3-5mg/kg IV OD (as per gentamicin guideline)
Severe Penicillin allergy (i.e. anaphylaxis):
Ciprofloxacin 400mg IV BD
+ Teicoplanin 400mg IV BD for 3 doses then 400mg IV OD (depending on renal function) + Gentamicin 3-5mg/kg IV OD (as per gentamicin guideline).
Neutropenic sepsis (Full guidance available on HUB)
Febrile neutropenia is defined as
•Temperature >38oC for more than 1 hour or a single reading >38.5oC and
•Neutrophil count of <0.5x109/litre or count of <1x109/litre with predicted decrease to <0.5x109/litre
1st line: Piperacillin/Tazobactam (Tazocin) 4.5g IV QDS
Non-severe Penicillin allergy (e.g. delayed rash):
Meropenem 1g IV TDS
Severe Penicillin allergy i.e. anaphylaxis:
+ Teicoplanin 400mg IV BD for 3 doses and then 400mg IV OD (depending on renal function) + Gentamicin 3-5mg/kg IV OD (as per gentamicin guideline)
For all other groups of patients, refer to full guideline on the HUB
EMPIRICAL USE OF ANTIBIOTICS
POCKET GUIDELINES FOR PRESCRIBING IN ADULTS
2017/2018
START SMART:
PLEASE AVOID ANTIBIOTICS IN THE ABSENCE OF CLINICAL EVIDENCE OF BACTERIAL INFECTION
Take cultures before antibiotic administration
Check allergy history and document nature of severity
Prescribe in line with BTUH policies / guidelines
Give first dose of antibiotic within 1 hour for severe / life-threatening infections
Document indication for antibiotic in medical notes and on drug chart
Record duration of therapy (stop / review date) on drug chart
Consult microbiology when appropriate
THEN FOCUS:
At 48 hours review diagnosis and need for antibiotics.
STOP antibiotics if no evidence of infection
SWITCH from IV to oral therapy
CHANGE antibiotics: de-escalate / substitute / add agents as per culture results
CONTINUE and review again after a further 24 hours
Document decisions in medical notes.
For hospital acquired infections check culture and sensitivity results before starting antibiotics.
Full guidelines are available on the intranet (the HUB)
All doses are based on NORMAL RENAL FUNCTION
For dosing in renal impairment check the antimicrobial doses for adult in renal impairment on the clinical HUB.
Gentamicin dosing – For patients with GFR <45ml/min, please refer to the Trust Guidelines. Prescribe 3mg/kg OD for those >75 years.
This is an aid for initial antibiotic prescribing.
All antibiotic prescriptions should be reviewed daily and consider further discussion with Microbiology, particularly if the initial presentation is complex (e.g. immunocompromised patients outside of the neutropenic sepsis protocol, returning traveler etc.) or if there is poor clinical response.
Indication and duration / review date must be written on the drug chart at time of prescribing.
MENINGITIS (Contact Microbiology)
Do NOT delay treatment
Start treatment as soon as blood cultures have been taken
1st Line: Ceftriaxone 2g IV BD (Give IM if no venous access) for 7-14 days
Severe Penicillin allergy: Chloramphenicol 1g IV QDS for 7-14 days
If Listeria suspected (e.g. patient pregnant or immunosuppressed or age>55 years):
Add Amoxicillin 2g IV 4 hourly
If Listeria suspected and penicillin allergic speak to microbiology
If gram positive cocci seen/cultured or if pneumococcal aetiology is likely (e.g. age>50yrs; sinus infection /otitis media / mastoiditis; csf leak; EtOH; immunocompromised):
Add Dexamethasone 0.15mg/kg IV QDS for 4 days. Must start either before, or with the first dose of antibiotic.
If GCS <15, recent seizures or suspected viral encephalitis:
Add Aciclovir 10mg/kg IV TDS for days
Review treatment in light of CSF cultures and PCR results
For further advice contact
Consultant Microbiologist:
Dr Edwards (ext 1249)/Microbiology Consultant via switchboard
Antimicrobial Pharmacist:
Bleep 6347 / 6005
Pharmacy Medicines Information: ext 3788
Out of hours contact switchboard for on-call Microbiology and/or Pharmacist
PRESCRIBING IN PENICLLIN ALLERGY
Produced by: Antimicrobial Stewardship Group
Approved: May 2017
Review: May 2018
Please check nature of allergy and confirm with patient and GP
• Drugs in RED are contra-indicated in penicillin allergy
• Drugs in ORANGE should be prescribed with caution
• Drugs in GREEN are considered safe
See Penicillin allergy (PenA) table for more information
Version 006
Q Pulse Number. 001/CP/0185
Adapted from UCLH antimicrobial pocket guide

2. DO NOT USE CAUTION SKIN & WOUND GASTROINTESTINAL
CLOSTRIDIUM DIFFICILE COLITIS
IV to ORAL SWITCH CRITERIA
GENTAMICIN DOSING
PENICILLIN ALLERGIES
Cellulitis
1st Line: Mild-moderate: Flucloxacillin 1g IV QDS (if patient is >70kg 2g QDS IV)
Moderate-severe: Benzylpenicillin 2.4g IV 6hourly with Clindamycin 600mg IV QDS
Penicillin Allergy: Clindamycin 600mg IV QDS
- Discontinue if diarrhoea develops
- Discuss with microbiology If patient >65 years
Switch to oral when appropriate
MRSA: Teicoplanin 400mg IV BD for 3 doses then 400mg OD (depending on renal function) + Sodium fusidate 500mg PO TDS
Isolate the patient
Take stool sample (stool type 5-7 →must take shape of container)
Stop precipitating antibiotics if possible
Avoid laxatives and anti-motility agents
Review use of proton pump inhibitors (PPIs)
Review response to therapy daily
1st Line: Metronidazole 400mg PO TDS
(if strict NBM or paralytic ileus use Metronidazole 500mg IV TDS)
If poor response to 1st line after one week switch to:
2nd Line: Vancomycin 125mg PO QDS
(Do not give vancomycin intravenously – it is not effective)
IV reviewed daily with a view to switch to oral therapy as soon as possible, according to the following criteria:
C Clinical Improvement observed: signs & symptoms of infection
improving & haemodynamically stable.
O Oral route not compromised (vomiting, malabsorption disorder,
NBM, Swallowing difficulties, unconscious, Severe diarrhoea)
N.B if fed via NG, PEG, RIG, NJ etc. consult ward Pharmacist
M Markers showing a trend towards normal
Apyrexial: Temp >36°C + <38°C for at least 24 hours
BP stable
Plus NOT more than one of:
Heart rate >90bpm
Respiratory Rate >20 breaths/min
WCC <4 or >12
S Specific/deep seated infection (see exclusion criteria below)
Exclusion Criteria
Certain infections require persistent IV therapy to ensure sufficient drug levels are attained at the site of infection to optimise response:
Deep abscess: Liver abscess, Cavitating pneumonia, intracranial abscess
Bone & Joint infections: Septic arthritis & Osteomyelitis
Emphysema
Staphylococcus aureus bacteraemia
Severe soft tissue infections: necrotising fasciitis, cellulitis
Cystic Fibrosis/Bronchiectasis
Infected implants/prosthesis
Meningitis/Encephalitis
Endocarditis/mediastinitis
Sepsis & Neutropenic sepsis
For <75 years
1st dose:
5mg/kg (max 500mg. Round up or down to nearest 20mg)
Dose is calculated using a dosing weight in obese patients
Dosing Weight = Ideal Body Weight X [actual Weight – ideal weight]
Subsequent doses:
Check pre-dose level before further doses are given
Pre-dose levels must be taken hours after a dose
Daily U+E’s
If <1mg/L give the same dose at 24 hour intervals
If 1-2mg/L Reduce dose to 75% of initial dose 24 hourly (Reduce dose once only. If levels still ≥1mg/L discuss with microbiology)
If >2mg/L No further doses until level is <1 (discuss with microbiology)
Dose Adjustment in Renal Impairment
Estimate GFR using creatinine clearance calculator
Creatinine Clearance (ml/min)
= [140 – age (years) x ideal body weight (kg) x F] /Serum creatinine
(F = 1.04 in females and 1.23 in males)
GFR (ml/min)
10-40 Dose 3mg/kg (max 240mg dose rounded to nearest 20mg)
<10 Dose 2mg/kg (max 160mg dose rounded to nearest 20mg)
Check Levels hours after 1st dose. Re-dose only when levels <1mg/L
Dose Adjustment in >75 years
1st Dose: 3mg/kg (max 240mg. Dose rounded to nearest 20mg)
Not all penicillins sound like they contain a penicillin
PENICILLINS CAN KILL IF GIVEN TO A PATIENT WITH PENICILLIN ALLERGY
For any antibiotics NOT listed below please contact your ward Pharmacist or Medicines Information
Biliary tract infection/ Diverticulitis / Liver abscess/ Peritonitis/ Cholecystitis/ Cholangititis/ Post-operative Gastrointestinal Sepsis/ Biliary Sepsis
(including recent instrumentation e.g. ERCP)
1st Line: Co-amoxiclav 1.2g IV TDS +/- Gentamicin 3-5mg/kg IV stat
Penicillin allergy:
Teicoplanin 400mg IV BD for 3 doses then 400mg IV OD + Metronidazole 500mg IV TDS + Gentamicin 3-5mg/kg IV OD
Duration: 7-10 days
Acute Gastroenteritis
Isolate the patient
Avoid laxatives and anti-motility agents
Correct fluid and electrolytes
Mild symptoms
No antibiotic therapy required
Moderate to severe symptoms
(i.e. dehydration, bloody stools, abdominal pain, fever)
Send stool sample and await cultures
If antibiotics required discuss with Microbiology
CONSIDERED
SAFE
DO NOT USE
CAUTION
STOP! Contraindicated in Penicillin Allergy
Amoxicillin or ampicillin
Benzylpenicillin
Co-Amoxiclav (Augmentin® = Amoxicillin + Clavulanic acid)
Flucloxacillin
Penicillins (Phenoxymethylpenicillin, Procaine, Benzathine)
Piperacillin / Tazobactam (Tazocin®)
Pivmecillinam
Temocillin
Ticarcillin + clavulanic acid (Timentin)
BONE & JOINT (Contact Microbiology)
PELVIC INFLAMMATORY DISEASE
CAUTION! Use with caution in Penicillin Allergy
Consult Microbiology before prescribing
AVOID if history of severe allergy. CAUTION if non-severe allergy
Cefalexin Ceftriaxone Meropenem
Cefixime Cefuroxime Aztreonam
Cefotaxime Ertapenem
Ceftazidime Imipenem
Ceftaroline fosamil . Ceftolozane + Tazobactam
Approximately 10% of penicillin sensitive patients may be sensitive to a drug in this group.
Discuss with Microbiology if MRSA suspected and in all cases of suspected prosthetic joint infection
Osteomyelitis
1st Line: Flucloxacillin 1-2g IV QDS + Sodium Fusidate 500mg PO TDS
Pen allergy: Teicoplanin 800mg IV BD for 3 doses then 800mg IV OD (depending on renal function) + Sodium Fusidate 500mg PO TDS
Add Gentamicin 3-5mg/kg IV OD if systemically unwell
Duration if acute 42 days
Duration if chronic 90 days
Septic Arthritis
1st Line: Benzylpenicillin 1.2g IV QDS + Flucloxacillin 1g IV QDS
2nd Line: Teicoplanin 800mg IV BD for 3 doses the 800mg OD (depending on renal function) + Clindamycin 600mg QDS IV (contact microbiology if patient >65 yrs)
Duration: 4-6 weeks
NB discontinue clindamycin if diarrhoea develops
1st Line: Ceftriaxone 2g IV stat + Doxycycline 100mg PO BD
+ Metronidazole 400mg PO TDS
Penicillin allergy: If severe allergy then discuss with Microbiology
Total duration: 14 days
NB Gonococcal resistance is an increasing clinical problem. Please discuss outpatient treatment with either Microbiology or GU Medicine. Please discuss all cases of tubo-ovarian abscesses with microbiology.
SAFE! Considered Safe in Penicillin Allergy
Amikacin Fosfomycin Sodium Fusidate
Azithromycin Gentamicin Teicoplanin
Chloramphenicol Levofloxacin Tetracycline
Clarithromycin Linezolid Trimethoprim
Clindamycin Lymecycline Tobramycin
Colistin Metronidazole Tigecycline
Co-Trimoxazole Moxifloxacin vancomycin
Ciprofloxacin Minocycline
Daptomycin Nitrofurantoin
Doxycycline Oxytetracycline
Erythromycin Ofloxacin
Rifampicin
MRSA SUPPRESSION THERAPY
Refer to MRSA screening policy on HUB for further information.
Treatment for 5 days
1st line: Mupirocin (Bactroban®) nasal ointment TDS to both nostrils
Octenisan® body wash OD
Octenisan® shampoo hair on days 2 and 4
For alternative agents in case of adverse effects or resistance contact Infection Prevention & Control