hse se antibiotic guidelines 2012 booklet

Guidelines for the empiric use of antimicrobials in adults HSE South East Hospital Network

June 2012

Review Date: June 2013

Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6


Acknowledgement: Gentamicin and Vancomycin Algorithims page 19 & 21 adapted from original algorithims kindly provided by Beaumont/Connolly Hospital Antimicrobial Stewardship Committee in 2011.

Issued by: Dr. M. Hickey & Dr. D. Keady June 2006

Revised by: Dr. M. Hickey June 2007

Revised by: Dr. M. Hickey, Dr. M. Doyle & Dr. B. Carey April 2008

Revised by: Dr. M. Hickey, Dr. M. Doyle & Dr. B. Carey June 2009

Revised by: Dr. M. Hickey & Dr. M. Doyle June 2010

Revised by: HSE SE Antimicrobial Stewardship Group June 2011

Revised by: HSE SE Antimicrobial Stewardship Group June 2012

Review Date: June 2013

Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6 1

Table of Contents Page No.

General Guidance 2-3

Restricted and Reserve Antimicrobials 4

MRSA 5

Urinary Tract Infection 6

Respiratory Tract Infection 7-12

Endocarditis & Intra-abdominal Infections 12

Gastro-intestinal Infection 13

Septicaemia & Neutropenic Sepsis 14

Bone and Joint Infections 15

Skin and Soft tissue Infections 15

Central Nervous System 16

ENT infections 16

Genital Tract Infection 17

Gentamicin 18-19

Glycopeptides: Vancomycin, Teicoplanin 20-21

Switch from IV to PO 22

Oral Bioavailability and Relative Costs 23-24

2

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

GEN

ERA

L G

UID

AN

CE

1.

NB: T

he p

resc

riber

shou

ld a

lway

s che

ck p

resc

ribing

info

rmat

ion

such

as c

autio

ns,

cont

raind

icatio

ns, i

nter

actio

ns a

nd si

de e

ffects

whe

n co

nsid

ering

ant

imicr

obia

l the

rapy

. Ens

ure

infor

mat

ion

on a

ntim

icrob

ial p

resc

ribing

, inc

luding

risk

s and

side

effe

cts a

ssoc

iate

d w

ith

antim

icrob

ial t

reat

men

t, is

avai

labl

e to

pat

ients

or t

heir

legal

gua

rdia

ns.¹

2.

Wher

e pos

sible

indica

te int

ende

d dur

ation

of th

erap

y at p

oint o

f init

ial pr

escri

bing.

Revie

w IV

antim

icrob

ial

ther

apy d

aily.

3.

Docu

ment

indic

ation

for t

hera

py an

d int

ende

d dur

ation

in m

edica

l rec

ord.

Note

thes

e guid

eline

s are

inten

ded

for e

mpiri

c the

rapy

. Rati

onali

se w

hen m

icrob

iolog

y res

ults b

ecom

e ava

ilable

.

4.

Piper

acilli

n-taz

obac

tam an

d co-

amox

iclav

prov

ide g

ood

anae

robi

c cov

er. C

oncu

rrent

metr

onida

zole

is NO

T req

uired

unles

s the

re is

gros

s fae

cal c

ontam

inatio

n – e.

g. fa

ecal

perit

onitis

. Tre

atmen

t of a

spira

tion

pneu

monia

does

NOT

requ

ire ad

dition

of m

etron

idazo

le to

eithe

r of t

hese

antib

iotics

.

5.

Some

antib

iotics

e.g.

cipro

floxa

cin, f

usid

ic ac

id an

d met

ronid

azol

e hav

e exc

ellen

t ora

l bi

oava

ilabi

lity

and t

he or

al ro

ute s

hould

be us

ed w

here

possi

ble. I

V for

mulat

ions o

f the

se sh

ould

only

be

used

if th

e pati

ent is

not a

bsor

bing

or u

nabl

e to

hav

e or

al m

edica

tions

.

3

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

6.

Oral

switc

h – co

nside

r whe

n pati

ent is

afeb

rile a

nd in

fecti

on pa

rame

ters a

re se

ttling

for 4

8 ho

urs a

nd no

rmal

oral

abso

rptio

n. Ge

nera

lly N

OT ap

prop

riate

in m

ening

itis,

endo

card

itis,

febr

ile n

eutro

penia

or ac

ute

oste

omye

litis/

sept

ic ar

thrit

is.

7.

For o

ral s

witch

guide

lines

see p

g 22.

Ora

l swi

tch is

usua

lly to

PO fo

rmula

tion o

f sam

e ant

ibioti

c whe

re

avail

able,

exce

pt IV

pen

icillin

to P

O am

oxici

llin as

oral

abso

rptio

n of p

enici

llin is

very

poor.

8.

Penic

illin

aller

gy: o

btai

n &

docu

men

t pro

per h

istor

y. If

IgE m

ediat

ed al

lergic

reac

tion (

e.g.

anap

hylax

is, an

gione

uroti

c oed

ema,

imme

diate

urtic

aria)

avoid

all b

eta-la

ctams

. If r

ash o

nly, a

ceph

alosp

orin

may b

e con

sider

ed. E

ryth

romy

cin is

often

NOT

a go

od su

bstit

ute.

9.

Fluclo

xacil

lin an

d oth

er be

talac

tams s

uch a

s co-

amox

iclav

, pipe

racil

lin-ta

zoba

ctam,

ceph

alosp

orins

and

mero

pene

m do

not

cove

r MRS

A.

10.

Risk o

f Clos

tridiu

m dif

ficile

asso

ciated

with

all a

ntibi

otic u

se. P

artic

ular r

isk w

ith al

l flur

oquin

olone

s (e.g

. lev

oflox

acin

and c

iprofl

oxac

in), c

linda

mycin

and c

epha

lospo

rins.


Restricted/Reserve Antimicrobials: A Cochrane review has found that reserving access to selected antimicrobials is the most effective component of any Antimicrobial Stewardship Programme.10

Below is the list of Restricted and Reserve antimicrobials for the SE Acute Hospital Network.These antimicrobials should only be prescribed when this is in line with the recommendations of this guideline or following discussion with the Clinical Microbiologist. Indication for therapy and any discussions/advice from the Clinical Microbiologist should be documented accurately in patient’s medical record.Restrictions are in place which limit access to these Antimicrobials. Please refer to South East Acute Hospital Network Guidelines for use of Reserve and Restricted Antimicrobials for details.

Restricted Antimicrobials *Reserve Antimicrobials IV Piperacillin/Tazobactam IV Cefotaxime IV Ceftriaxone IV Ceftazidime IV Ciprofloxacin IV Erythromycin IV/PO Levofloxacin IV OfloxacinIV Chloramphenicol IV ColistinIV/PO Clindamycin IV DaptomycinIV Teicoplanin IV TigecyclineIV Vancomycin AntifungalsIV/PO Linezolid Liposomal Amphotericin BIV Meropenem Anidulafungin Caspofungin Voriconazole Posaconazole

* Reserve antimicrobials should only be prescribed when recommended by a Consultant and following discussion with the Clinical Microbiologist.


MRSA (Meticillin Resistant Staphylococcus aureus)

Infection with MRSA should be suspected if: • Patient has previously been colonized with MRSA.

(Please check patients notes or check laboratory enquiry for ‘SIF code’)

• Recent hospitalization (within 12 months)

• Transfer from another hospital or long term care facility.

• Other situation where increased clinical suspicion of MRSA (Please refer to Policy on Control and Prevention of Meticillin Resistant Staphylococcus aureus (MRSA) in Acute Hospitals in the HSE/SE. November 2009 for additional information)²

If MRSA infection is suspected, consider including a glycopeptide (Vancomycin or Teicoplanin, see page 20) in the empiric treatment regimen.

MRSA eradication: Please refer to Policy on Control and Prevention of Meticillin Resistant Staphylococcus aureus (MRSA) in Acute Hospitals in the HSE/SE. November 2009.²

6

Urina

ry Tr

act

Infe

ction

s³Lo

wer

urin

ary

tract

infec

tion

(unc

ompli

cated

)

Hosp

ital a

cquir

ed o

rre

curre

nt U

TI o

rco

mpl

icate

d UT

I

Cath

eter

ass

ocia

ted

UTI

Pyelo

neph

ritis

Pros

tatit

is

First

line:

Nitro

fura

ntoi

n M

R 10

0mg

BD P

O fo

r 5 d

ays

Seco

nd lin

e: Co

-Amo

xiclav

625

mg TD

S PO

for 3

days

Refe

r to r

ecen

t cult

ure r

esult

s.If

septi

caem

ic: as

for p

yelon

ephr

itis

For p

atien

ts wi

th ca

thete

r asso

ciated

UTIs

,an

tibiot

ics ar

e unli

kely

to re

solve

the U

TIun

less t

he ca

thete

r is r

emov

ed. I

f sys

temic

seps

is su

spec

ted tr

eat a

s per

Pyelo

neph

ritis.

Pipe

racil

lin-ta

zoba

ctam

4.5

g TD

S fo

r 10-

14 d

ays o

r gen

tamici

n (se

e pag

e 18

for d

osing

regim

en).

Cipr

oflox

acin

500-

750m

g BD

PO

for

2-6

wee

ks.

Nitro

fura

ntoin

is no

t app

ropr

iate i

f cre

atinin

ecle

aran

ce is

< 5

0 ml

/min.

In pr

egna

ncy n

itrof

uran

toin m

ay al

so be

used

bu

t it sh

ould

be av

oided

at te

rm.

Patie

nts w

ith re

curre

nt U

TIs m

ay ha

vere

sistan

t org

anism

s. Us

e 7-1

0 da

ys tr

eatm

ent

in ma

les.

Send

bloo

d cult

ures

and M

SU. R

ation

alise

ther

apy a

s soo

n as p

ossib

le. Ch

eck c

ultur

e an

d ant

imicr

obial

sens

itivity

resu

lts.

Relap

se co

mmon

. Foll

ow up

advis

ed. C

heck

antim

icrob

ial se

nsitiv

ity w

here

possi

ble.

Co

nditi

on

Antib

iotic

Co

mm

ents

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

7

CO

MM

UN

ITY

ACQ

UIR

ED P

NEU

MO

NIA

Base

d o

n “

Bri

tish

Thora

cic

Soci

ety g

uid

elin

es f

or

the

managem

ent

of

com

munity a

cquir

ed p

neu

monia

in a

dults:

Update

2009.”

4

Thes

e gu

idel

ines

are

not

aim

ed a

t: (a

) Pat

ient

s w

ith k

now

n pr

edis

posi

ng c

ondi

tions

suc

h as

can

cer

or im

mun

osup

pres

sion

adm

itted

w

ith p

neum

onia

to s

peci

alis

t uni

ts su

ch a

s on

colo

gy, h

aem

atol

ogy,

pal

liativ

e ca

re, i

nfec

tious

di

seas

e un

its o

r A

IDS

units

(b

) Adu

lts w

ith n

on p

neum

onic

LRT

I, in

clud

ing

illne

sses

labe

lled

as a

cute

bro

nchi

tis, a

cute

ex

acer

batio

ns o

f CO

PD o

r “c

hest

infe

ctio

ns”

Co

nditi

on

Antib

iotic

Co

mm

ents

Resp

irato

ry Tr

act

Infe

ction

sCo

mm

unity

Acq

uired

Pneu

mon

iaCo

mm

unity

Acq

uired

Pne

umon

ia:

Asse

ss se

verit

y usin

g CUR

B-65

scor

e as p

er

BTS g

uideli

nes:

Conf

usion

(new

onse

t)Ur

ea >

7mmo

l/LRR≥3

0/mi

nBP

- hy

poten

sive:

SBP <

90mm

Hg or

DBP

≤60m

mHg

Age ≥

65

year

s

CURB

-65

score

shou

ld be

used

with

caut

ion

in yo

unge

r pati

ents

as it

may u

nder

estim

ate

seve

rity i

n the

se pa

tient

s.

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

8

Co

nditi

on

Antib

iotic

Co

mm

ents

Com

mun

ity

Acqu

ired

Pneu

mon

ia

Low

seve

rity

(CUR

B65

= 0-

1)<3

% mo

rtality

Mod

erat

e Se

verit

y(C

URB6

5 =

2)9%

mor

tality

High

seve

rity

(CUR

B65

= 3-

5)15

- 40

% mo

rtality

Legio

nello

sis

Amox

icillin

500

mg

tds P

O. (I

V if

PO

adm

inist

ratio

n no

t pos

sible.

)Pe

nicilli

n alle

rgy:

clarit

hrom

ycin

500m

g BD

or do

xycy

cline

200

mg O

D PO

load

ing do

seth

en 1

00mg

OD

PO.

Amox

icillin

500

mg-

1.0g

tds P

O pl

us

clarit

hrom

ycin

500m

g bd

PO.

(IV if

PO

adm

inist

ratio

n no

t pos

sible.

)Pe

nicilli

n alle

rgy:

PO do

xycy

cline

Co-a

mox

iclav

1.2

g td

s IV

plus

clar

ithro

myc

in 50

0mg

bd IV

.(If

legi

onell

a st

rong

ly su

spec

ted

cons

ider

add

ing

levofl

oxac

in)Pe

nicilli

n alle

rgy (

NOT I

gE m

ediat

ed re

actio

n/a

naph

ylaxis

): ce

furo

xime 7

50mg

-1.5

g tds

IV pl

us cl

arith

romy

cin 5

00mg

bd IV

.Se

vere

IgE m

ediat

ed re

actio

n/an

aphy

laxis

to pe

nicilli

n: lev

oflox

acin

500m

g PO/

IV O

D(1

2 ho

urly

if se

vere

).

Levo

floxa

cin 5

00m

g PO

/IV

OD (1

2ho

urly

if se

vere

)

No m

icrob

iolog

ical te

sts re

quire

d. 7

days

appr

opria

te an

tibiot

ic th

erap

y is

reco

mmen

ded.

Micro

biolog

y: Se

nd bl

ood c

ultur

es,

sput

um, u

rine f

or pn

eumo

cocca

l ant

igen.

7 da

ys ap

prop

riate

antib

iotic

ther

apy i

s re

comm

ende

d. Mi

crobio

logy:

Send

bloo

d cult

ures

, spu

tum

(requ

estin

g leg

ionell

a cult

ure)

, urin

e for

pn

eumo

cocca

l ant

igen a

nd le

gione

lla an

tigen

, CR

P.Co

nside

r swi

tch to

PO an

tibiot

ics as

soon

as

clinic

al im

prov

emen

t occu

rs an

d pati

ent is

ap

yrex

ial fo

r 24

hour

s.7-

10 d

ays a

ppro

priat

e ant

ibioti

cs is

prop

osed

. This

may

need

to be

exten

ded t

o 14

-21

days

acco

rding

to cl

inica

l judg

emen

t.

IV ro

ute t

o be u

sed i

f ora

l abs

orpti

on

unre

liable

. Ear

ly or

al sw

itch w

here

possi

ble.

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

9

CURB6

5 s

core

New

ons

et m

enta

l con

fusi

onU

rea>

7 m

mol

/LRe

spira

tory

rat

e ≥

30/m

inSy

stolic

blo

od p

ress

ure

<90m

mH

g an

d/or

dias

tolic

blo

od p

ress

ure ≤6

0mm

Hg

Age

≥65

yea

rs

Low

ris

k0

or 1

poi

ntIn

term

edia

te r

isk

2 po

ints

Hig

h ris

k3-

5 po

ints

Inpa

tient

man

agem

ent

Inpa

tient

man

agem

ent

Ora

l am

oxic

illin

and

mac

rolid

eIn

trave

nous

co-

amox

icla

van

d m

acro

lide

Out

patie

ntm

anag

emen

t

Ora

l am

oxic

illin

BTS

-rec

om

men

ded

ther

apy f

or

Com

munity A

cquir

ed P

neu

monia

(Tak

en fr

om J

Ant

imic

rob

Che

mot

her

2012

; 65:

pag

e 61

2) 4

CU

RB-6

5 sc

ore

shou

ld b

e us

ed w

ith c

autio

n in

you

nger

pat

ient

s as

it m

ay u

nder

estim

ate

seve

rity

in th

ese

patie

nts

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

10

Co

nditi

on

Antib

iotic

Co

mm

ents

Resp

irato

ry

Trac

tIn

fecti

ons

Heal

th ca

reas

socia

ted

pneu

mon

ia5

Hosp

ital a

cquir

edpn

eum

onia

6

Patie

nts f

rom

nursi

ng ho

me/c

hron

ic ca

renu

rsing

facil

ity/r

ecen

t hos

pitali

satio

n ref

er to

algor

ithm

page

11.

With

in 4

days

of ad

missi

on &

no re

cent

antib

iotics

: Co

-am

oxicl

av 6

25m

g TD

S PO

or 1

.2g

TDS

IV

for 8

day

s.

Penic

illin a

llerg

y (NO

T IgE

med

iated

reac

tion

/ana

phyla

xis):

Cefu

roxim

e 750

mg -

1.5g

TDS I

V. Se

vere

IgE m

ediat

ed re

actio

n/an

aphy

laxis

to pe

nicilli

n: Le

voflo

xacin

500

mg PO

/ IV

OD.

(12

hour

ly if

seve

re).

More

than

4 da

ys si

nce a

dmiss

ion :

Pipe

racil

lin-ta

zoba

ctam

4.5

g TD

S IV

If ris

k fac

tors f

or M

DR pa

thog

ens s

ee pa

ge 1

1.

Penic

illin a

llerg

y: if

NOT I

gE

media

ted/a

naph

ylaxis

and i

f pne

umon

ia is

not s

ever

e co

nside

r cef

urox

ime 1

.5g T

DS IV

.Se

vere

IgE m

ediat

ed re

actio

n/an

aphy

laxis

tope

nicilli

n: Le

voflo

xacin

500

mg PO

/IV O

D (1

2ho

urly

if se

vere

).

If pa

tient

is co

nsid

ered

to b

e hig

h ris

kfo

r MRS

A, co

nsid

er a

dding

Teico

plan

in

Send

sput

um fo

r cult

ure i

f pos

sible

Cons

ider l

egion

ella r

isk. I

n at r

isk pa

tient

s se

nd ur

ine fo

r leg

ionell

a ant

igen a

nd ad

d cla

rithr

omyc

in em

pirica

lly. S

end s

putu

m fo

r Le

gione

lla cu

lture

, if po

ssible

For c

onfir

med l

egion

ellos

is se

e pag

e 8.

If pa

tient

is co

nsid

ered

to b

e hig

h ris

kfo

r MRS

A, co

nsid

er a

dding

Van

com

ycin

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

11

Patie

nts w

ith H

CAP s

hould

be id

entifi

ed an

d the

n di

vide

d on

the

basis

of s

ever

ity o

f illn

ess t

o guid

e init

ial th

erap

y. Pa

tient

s in e

ach g

roup

are t

hen

furth

er d

ivid

ed b

ased

on

whe

ther

th

ey h

ave

risk

facto

rs fo

r dru

g-re

sista

nt (M

DR) p

atho

gens

that

includ

e: re

cent

antib

iotic

ther

apy i

n the

past

6 mo

nths

, rec

ent h

ospit

aliza

tion i

n the

past

3 mo

nths

, the

pres

ence

of im

mune

su

ppre

ssion

, and

poor

func

tiona

l stat

us as

defin

ed by

activ

ities o

f dail

y livi

ng. C

AP, c

ommu

nity-

acqu

ired p

neum

onia;

HAP

, hos

pital-

acqu

ired p

neum

onia.

*A

dapte

d fro

m Br

ito V,

et al

. Cur

rent

Opin

ion in

Infe

ctiou

s Dise

ases

200

9, 2

2:31

6-32

5

Alg

ori

thm

for

hea

lthca

re-a

ssoci

ate

d p

neu

monia

(H

CA

P)

ther

apy*

HCA

P p

rese

nt:

Pat

ient

from

nur

sing

hom

e/ch

roni

c ca

re fa

cilit

y, r

ecen

t hos

pita

lizat

ion

Ass

ess se

veri

ty o

f ill

nes

s (U

se C

URB

65 s

core

)

AN

D

Pres

ence

of r

isk

fact

ors

for

mul

ti-dr

ug r

esis

tant

(MD

R) p

atho

gens

(rec

ent a

ntib

iotic

s, r

ecen

t hos

pita

lizat

ion,

poo

r fu

nctio

nal s

tatu

s, im

mun

e su

ppre

ssio

n)

Seve

re p

neu

monia

(Bas

ed o

n C

URB

65 s

core

)

No

(CU

RB65

sco

re m

ild o

r m

oder

ate)

Yes

(CU

RB65

sco

re 3

or

>)

0-1

Risk

s fo

r M

DR

Trea

t for

com

mon

CA

P Pa

thog

ens

See

CA

P p.

8

≥1 R

isk

for

MD

RTr

eat f

or M

DR

Path

ogen

sSe

e H

AP

p.10

≥2 R

isks

for

MD

RTr

eat f

or M

DR

Path

ogen

sSe

e H

AP

p.10

0 Ri

sks

for

MD

RTr

eat a

s se

vere

CA

PSe

e C

AP

p.8

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

12

Co

nditi

on

Antib

iotic

Co

mm

ents

Resp

irato

ry Tr

act

Infe

ction

s

Endo

card

itis

Intra

-abd

omina

linf

ectio

ns

Acut

e ex

acer

batio

n of

COPD

(no c

onso

lidati

on on

CXR)

Exam

ples

: Per

itonit

is,

Dive

rticu

litis,

Bilia

ry tr

act

infec

tions

Panc

reat

itis

Seve

re a

cute

necro

tising

Pan

creat

itis

Antib

iotic

s may

not

be

requ

ired

See “

Comm

ents”

Co-a

mox

iclav

ora

l or I

V de

pend

ing o

nse

verit

y fo

r 5-7

day

s. Re

view

nee

dfo

r IV

ther

apy

on a

dai

ly b

asis.

Penic

illin a

llerg

y : Cl

arith

romy

cin 5

00mg

BD

daily

PO fo

r 5-7

days

Seek

adv

ice fr

om M

icrob

iolo

gy.

Co-a

mox

iclav

1.2

g TD

S IV

for 7

-10

days

.

First

line:

Co-a

mox

iclav

1.2

g TD

S IV

Se

cond

line:

Piper

acilli

n-taz

obac

tam 4

.5g T

DS

IV. Co

nside

r add

ition o

f gen

tamici

n

First

line:

Pipe

racil

lin-ta

zoba

ctam

4.5

g TDS

IV.

Cons

ider a

dditio

n of g

entam

icin

Seco

nd lin

e: Me

rope

nem

1g TD

S IV

Cons

ider a

ntibi

otic t

hera

py if

2 or

mor

epr

esen

t:In

creas

ed br

eath

lessn

ess

Incre

ased

sput

um vo

lume

Sput

um pu

rulen

ceIf

cons

olida

tion o

n CXR

trea

t as C

AP.

Send

3 se

ts of

bloo

d cult

ures

.

Penic

illin a

llerg

y (NO

T IgE

med

iated

reac

tion /

anap

hylax

is):

Cefu

roxim

e 750

mg- 1

.5g T

DS an

d me

tronid

azole

500

mg TD

S IV+

/- ge

ntam

icin.

Seve

re hy

perse

nsitiv

ityre

actio

n/an

aphy

laxis

to pe

nicilli

ns:

metr

onida

zole

+ ge

ntam

icin

Discu

ss wi

th M

icrob

iolog

y tea

m as

soon

as

possi

ble

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

13

Co

nditi

on

Antib

iotic

Co

mm

ents

Gast

ro-in

test

inal

Infe

ction

sAc

ute

gast

roen

terit

is

Clos

tridi

um d

ifficil

eAs

socia

ted

Dise

ase

(CDA

D)

Antib

iotic

Treatm

ent m

ost o

ften n

ot ne

cessa

ry.

Cons

ider

ant

ibio

tics O

NLY

ifim

mun

osup

pres

sed

or si

gns o

fsy

stem

ic se

psis.

Di

scus

s with

micr

obio

logy

team

.

Non-

seve

re C

DAD:

Met

ronid

azol

e 40

0mg

TDS

PO fo

r 10

days

Seve

re C

DAD:

Early

surg

ical r

eview

reco

mmen

ded

Vanc

omyc

in 12

5mg

PO Q

DSfo

r 10

days

Inab

ility t

o tak

e ora

l med

icatio

ns:

Metro

nidaz

ole 5

00 m

g IV T

DS/Q

DS fo

r 10

days

Ensu

re ap

prop

riate

isolat

ion w

ith st

anda

rdan

d con

tact p

reca

ution

s are

insti

tuted

. Sen

dsto

ol sp

ecim

en to

labo

rator

y. No

te a

ll pa

tient

s with

une

xpla

ined

diar

rhoe

a sh

ould

be

isola

ted.

Disc

ontin

ue o

ther

ant

ibio

tics i

fpo

ssib

le.Di

scuss

with

micr

obiol

ogy t

eam

if no

tre

spon

ding t

o the

rapy

.

Refe

r to H

SE SE

Clos

tridiu

m dif

ficile

guide

lines

in th

e Inf

ectio

n Con

trol M

anua

lav

ailab

le on

all w

ards

.8

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

14

Co

nditi

on

Antib

iotic

Co

mm

ents

Sept

icaem

ia

Neut

rope

nic se

psis

9

Asse

ss pa

tient

re po

ssible

focu

sof

infe

ction

–e.g

. urin

ary t

ract,

sk

in/so

ft tis

sue,

abdo

mina

l, ch

est,

neur

ologic

al., c

ommu

nity

or ho

spita

l acq

uired

, tra

vel

histor

y, re

cent

antib

iotic

ther

apy,

pres

ence

of pr

osth

etic

devic

es, in

trava

scular

cath

eters,

etc

.

Ensu

re bl

ood c

ultur

es ta

ken.

See i

ndivi

dual

infec

tion t

reatm

ent g

uideli

nes f

or ap

prop

riate

ther

apy.

Initi

al e

mpi

rical

ther

apy

if no

obv

ious

so

urce

: Pip

erac

illin-

tazo

bacta

m 4

.5g

IV T

DS. C

onsid

er ad

ding g

entam

icin i

f ha

emod

ynam

ically

unsta

ble /

seve

re in

fecti

on.

Cons

ider n

eed f

or ad

dition

al gr

am po

sitive

co

ver e

.g va

ncom

ycin(

or te

icopla

nin if

patie

nt

is alr

eady

on ge

ntam

icin)

Initi

al Em

piric

ther

apy:

Pip

erac

illin-

tazo

bacta

m 4

.5g

QDS

IV. A

dd ge

ntam

icin

if co

mplic

ation

s (e.g

. hyp

otens

ion, p

neum

onia

or an

timicr

obial

resis

tance

susp

ected

).Co

nside

r add

ing va

ncom

ycin

or te

icopla

ninfo

r spe

cific c

linica

l indic

ation

s e.g.

susp

ected

CVC-

relat

ed in

fecti

on or

comp

licati

ons a

s abo

ve.

Penic

illin a

llerg

y (No

t IgE

med

iated

reac

tion/

anap

hylax

is): C

eftaz

idime

2g T

DS IV

plus v

anco

mycin

or te

icopla

nin.

Seve

re Ig

E med

iated

reac

tion/

anap

hylax

is to

penic

illin:

Cipro

floxa

cin pl

us ge

ntam

icin p

lustei

copla

nin

Cons

ider

if p

atien

t at r

isk fo

r inf

ectio

ndu

e to

MRS

A , i

f so,

add

van

com

ycin.

Cons

ider o

ther

mult

iresis

tant

org

anism

s.Ch

eck p

revio

us la

bora

tory r

esult

sPe

nicilli

n alle

rgy:

Gent

amici

n, me

tronid

azole

plu

s teic

oplan

in

At le

ast 2

sets

of b

lood

cultu

res

reco

mm

ende

d fro

m ea

ch lu

men o

f CVC

and p

eriph

eral

OR pe

riphe

ral X

2 if

no CV

C is

pres

ent.

Cultu

re of

urine

, stoo

l, CSF,

skin

and

resp

irator

y spe

cimen

s sho

uld be

guide

d by

clinic

al sig

ns /

symp

toms b

ut sh

ould

not

be p

erfo

rmed

rout

inely.

Pers

isten

t fev

er a

fter 4

day

s of

antib

iotic

ther

apy:

cons

ider

add

ing

empi

ric a

ntifu

ngal

age

nt.

Cons

ider n

eed f

or vi

ral te

sting

&/o

r ant

ivira

lth

erap

y if c

linica

l indic

ation

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

15

Co

nditi

on

Antib

iotic

Co

mm

ents

Bone

and

Joint

Infe

ction

s

Skin

and

soft

tissu

eIn

fecti

ons

Oste

omye

litis

/ Se

ptic

arth

ritis

Cellu

litis,

ery

sipela

s

Necro

tising

soft

tissu

einf

ectio

ns/N

ecro

tising

fa

sciti

s

Hum

an a

nd a

nimal

bite

s

Fluclo

xacil

lin 2

g QD

S IV

plus

sodi

um

fusid

ate

500m

g ta

bs T

DS P

O (o

r fus

idic

acid

susp

. 750

mg

TDS

PO)

Penic

illin a

llerg

y (NO

T IgE

med

iated

reac

tion/

anap

hylax

is): C

efur

oxim

e 1.5

g TDS

IV pl

us fu

sidic

acid

as ab

ove.

Seve

re Ig

E med

iated

reac

tion/

anap

hylax

is to

penic

illin:

Vanc

omyc

in plu

s fus

idic a

cid as

ab

ove.

Benz

ylpe

nicilli

n (p

enici

llin G

) 1.2

g-2.

4gQD

S IV

plus

fluc

loxa

cillin

1-2

g QD

S IV

Penic

illin a

llerg

y (NO

T IgE

med

iated

reac

tion/

anap

hylax

is): C

efur

oxim

e 750

mg-

1.5g

TDS

Seve

re Ig

E med

iated

reac

tion/

anap

hylax

isto

penic

illin:

Clind

amyc

in 1.

2g Q

DS IV

.

Refe

r to

surg

ical t

eam

urg

ently

.Pi

pera

cillin

-tazo

bacta

m 4

.5g

IV 6

to 8

hour

ly p

lus cl

indam

ycin

600m

g-1.

2gQD

S +/

- gen

tam

icin.

Disc

uss w

ith

Micro

biolog

ist.

Co-a

mox

iclav

625

mg

TDS

(or 1

.2g

TDS

IV if

seve

re) f

or 5

day

s

Adjus

t tre

atmen

t whe

n cult

ures

avail

able.

Treat

for 4

to 6

wee

ks. M

onito

r CRP

.

MRS

A kn

own

or h

igh

risk:

van

com

ycin.

Discu

ss po

ssible

oral

switc

h opti

ons w

ith th

e cli

nical

micro

biolog

y tea

m.

Switc

h to fl

uclox

acilli

n 500

mg-1

g QDS

POwh

en cl

inica

l impr

ovem

ent a

chiev

ed. T

reat

for 1

0 da

ys m

inimu

m.

NOTE

: sev

ere

cellu

litis

shou

ld n

ot b

etre

ated

with

a m

acro

lide

(ery

thro

myc

in/cla

rithr

omyc

in).

If MR

SA su

spec

ted us

e van

comy

cin.

Penic

illin a

llerg

y: Do

xycy

cline

100

mg B

D PO

.If

seve

re di

scuss

with

micr

obiol

ogy t

eam.

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

16

Co

nditi

on

Antib

iotic

Co

mm

ents

Cent

ral N

ervo

usSy

stem

ENT

Infe

ction

s

Men

ingiti

s

Ence

phal

itis

Acut

e ep

iglo

ttitis

Tons

illitis

/pha

ryng

itis

Sinu

sitis,

otit

is m

edia

Ceftr

iaxo

ne 2

g BD

IV If

Liste

ria ri

sk ad

dam

oxici

llin 2

g 4 hr

ly IV.

If St

rep p

neum

oniae

(pne

umoc

occu

s) su

spec

ted ad

d van

comy

cinun

til se

nsitiv

ities c

onfir

med.

Treat

for 1

4 da

ys if

pneu

moco

ccus.

Treat

for 7

days

if

menin

goco

ccus.

Seve

re Ig

E med

iated

reac

tion/

anap

hylax

is to

penic

illin:

chlor

amph

enico

l 1g I

V QD

S. If

immu

noco

mpro

mise

d add

vanc

omyc

in an

d co

-trim

oxaz

ole.

Acyc

lovir

10 m

g / kg

IV ev

ery 8

hour

s(u

se id

eal b

ody w

eight

in ob

ese p

atien

ts)

Ceftr

iaxo

ne 2

g BD

IV fo

r 7-1

0 da

ys

Phen

oxym

ethy

lpen

icillin

(pen

icillin

V)

666m

g QD

S PO

for 1

0 da

ysSe

vere

: Ben

zylpe

nicilli

n (pe

nicilli

n G) 1

.2g

QDS I

V

Co-a

mox

iclav

1.2

g IV

/ 6

25m

g TD

SPO

for 5

-7 d

ays

Seek

Micr

obio

logy

adv

ice.

Cons

ider

Dex

amet

haso

ne p

hosp

hate

fo

r bac

teria

l men

ingiti

s.(10

mg IV

6

hour

ly fo

r 2 to

4 da

ys. M

ust c

omme

nce

befo

re or

at sa

me tim

e as a

ntibi

otic).

Send

Blo

od cu

lture

s, th

roat

swab

,ED

TA b

lood

for P

CR +

/- C

SF. I

sola

tepa

tient

. Not

ify P

ublic

Hea

lth.

Adjus

t dos

e in r

enal

impa

irmen

t.Re

ques

t HSV

PCR

on CS

F.

Penic

illin a

llerg

y: Co

nside

r clin

damy

cin +

cipro

floxa

cin fo

r 7-1

0 da

ys.

Penic

illin a

llerg

y: Cla

rithr

omyc

in BD

500

mgPO

for 1

0 da

ys

Penic

illin a

llerg

y: Cla

rithr

omyc

in BD

500

mgPO

for 5

-7 da

ys

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6

17

Co

nditi

on

Antib

iotic

Co

mm

ents

Genit

al Tr

act

Infe

ction

Pelvi

c Infl

amma

tory

Dise

ase (

PID)

, Salp

ingitis

, Tu

bo-o

varia

n abs

cess

Outp

atien

t Rx:

Ceftr

iaxon

e 250

mg IM

or IV

as

single

dose

, the

n dox

ycyc

line P

O 10

0 mg

BD

+ me

tronid

azole

PO 4

00mg

TDS

Inpa

tient

Rx:

Ceftr

iaxon

e 1g o

nce d

aily I

V +

doxy

cycli

ne 1

00mg

BD

PO +

metr

onida

zole

PO

400m

g TDS

Seve

re 1

gE m

edia

ted

reac

tion/

ana

phyl

axis

to p

enici

llin: C

linda

mycin

900

mg I

V TDS

+

gent

amici

n (re

fer p

g 19)

+ do

xycy

cline

PO

100

mg B

D

Tota

l dur

atio

n of

ther

apy:

14

days

Switc

h to

ora

l/ou

tpat

ient r

egim

e w

hen

satis

facto

ry re

spon

se fo

r ≥ 2

4 ho

urs.

Note:

Fluo

roqu

inolo

nes (

eg ci

profl

oxac

in or

oflox

acin)

not r

ecom

men

ded

due t

o inc

reas

ing re

sistan

ce. R

ef: M

MWR

59 (R

R-12

)201

0 &

www.

cdc.g

ov/s

td/tre

atmen

t

In pr

egna

ncy,

a mac

rolid

e (az

ithro

mycin

or

eryth

romy

cin) m

ay be

used

inste

ad of

do

xycy

cline

.

Cons

ider t

reati

ng pa

rtner.

Gui

delin

es fo

r th

e em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tal N

etw

ork

June

201

2In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

une

2012

Rev

isio

n D

ate

June

201

3 Re

visi

on n

o 6


Do

se A

djus

tmen

t Le

vels

Com

men

tsSu

itable

for n

orma

l ren

al fu

nctio

n, cre

atinin

e clea

ranc

e >80

ml/m

in. D

ose

redu

ction

if <

80ml

/min,

seek

advic

e.

NB: G

enta

mici

n do

ses i

n ex

cess

of

400m

g IV

/ d

ay a

re ra

rely

re

quire

d.Do

se sh

ould

nev

er e

xcee

d 50

0mg

IV/D

ay.

See p

age 1

9 fo

r dos

ing al

gorit

him.

Endo

card

itis:

1mg/

kg IV

12

hour

ly.Se

rum

levels

:pr

e-dos

e lev

el <1

μg/m

l1

hour

post

dose

leve

l of 3

-5μg

/ml

(not

alway

s nec

essa

ry).

Norm

al re

nal f

uncti

on: t

wice

-wee

klyse

rum

monit

oring

may

be su

fficie

nt.

Abno

rmal

rena

l fun

ction

: dos

age s

hould

be ad

justed

acco

rding

to cr

eatin

inecle

aran

ce an

d dail

y ser

um as

say

resu

lts.

Take

pre-d

ose l

evel

befo

re th

e 3rd

dose

.

Pre-

dose

leve

ls ar

e re

quire

d to

mon

itor f

orto

xicit

yClo

tted s

ample

16-

18h a

fter t

he fi

rst do

se of

ge

ntam

icin s

hould

be <

1μg

/ml.

If >1

μg/m

l: Che

ck ti

ming

of l

evel,

revi

ew

dosin

g sc

hedu

le, ch

eck

rena

l fun

ction

, co

nsid

er a

ltern

ativ

e th

erap

y an

d se

ek a

dvice

if

nece

ssar

y.Se

e pag

e 19

for d

osing

algo

rithm

.If

cont

inuing

gent

amici

n and

rena

l fun

ction

is st

able,

repe

at lev

el tw

ice w

eekly

. Dail

y lev

els m

ay be

re

quire

d if r

enal

func

tion i

s uns

table.

Note

: 1-h

our p

ost d

ose

levels

are

not

ne

cess

ary

exce

pt in

end

ocar

ditis

– pl

ease

dis

cuss

on an

indiv

idual

basis

(see

comm

ents)

.**

*Clea

rly st

ate do

se, t

ime o

f dos

e and

time o

f bloo

dsa

mple

colle

ction

on th

e req

uest

form

. ***

Once

daily

Am

inogly

cosi

de

pro

toco

l:G

enta

mic

in 5

mg/k

g IV

daily

Infu

se in

100m

l of

glu

cose

5%

or

sodiu

m c

hlo

ride

0.9

% o

ver

30

-60

min

ute

s.

NB A

ntibio

tic

ass

ays

are

done

at

12

:00

Noon a

nd 4

.00

pm

Monday t

o F

riday a

nd

12:0

0 N

oon o

n S

atu

rdays

and S

undays.

Sam

ple

s m

ust

rea

ch t

he

labora

tory

inW

ate

rford

Reg

ional H

osp

ital o

ne

hour

bef

ore

thes

e above

tim

es.


Is Creatinine Clearance (CrCl) >80ml/min?

CrCl = (140-Age) x Weight(kg) (Use ODW if BMI>30)* x 1.23 (males) or 1.04 (females)Serun Creatinine(µmol/L)

**If anuric (<500mls/day), treat as CrCl<10ml/min

No

No

Yes

Yes

Give first dose of IV Gentamicin 5mg/kg*

(based on Actual Body Weight or ODW if obese*). Record actual time of dose (Ideally 4-6pm)

Dose should not exceed 500mg/day

CrCl(ml/min) Dose50-80 4mg/kg30-50 3mg/kg*10-30 2mg/kg*<10 1-2mg/kg* redose when level <1µg/ml

Is trough level <1µg/ml

Continue current regimen. Check time dose was given andsample taken. Was level taken at

16-18 hours after dose?

Is trough level>1(µg/ml) but<2(µg/ml) andtreatment still

Indicated?

Seek advice from Pharmacy

or Clinical Microbiology

Reduce once daily dose by 1mg/kg*

Repeat trough levels and serum creatinine concentration twice weekly (if renal function is poor/

deteriorating and/or previous trough levels are high, then levels need to be

checked more frequently e.g. daily)

Take blood for serum gentamicin level 16-18 hours after FIRST dose.Record actual time of sampling.

(4pm dosing = 8-10am level, 6pm dosing = 10am-12noon level)

*Weight used should be actual body weight (ABW) or for obese patients (BMI>30), an obese dosing weight

(ODW) must be calculated.ODW = IBW + 0.4 (ABW - IBW)

Dose should never exceed 500mg.BMI= Weight (kg)/Height (m)²IBW (males) Kg= 50 + (0.9 x no. of cm over 152cm)IBW (females) Kg= 45.5 + (0.9 x no. of cm over 152cm)1 foot = 30.5com, 1 inch = 2.54cm

NoYes

Yes No

Adult Single Daily Dosing Algorithm for Gentamicin(Exclusions: Endocarditis & renal impairment. Caution required in CF patients,

pregnant women & patients with severe burns.)


Va

ncom

ycin

Dosa

ge S

ched

ule

Leve

ls Co

mm

ents

(refe

r to d

osing

algo

rithm

page

21)

: 15-

20m

g/kg

(actu

al b

ody

weig

ht).

In se

vere

/com

plica

ted

infec

tions

ahig

her d

ose

+/- l

oadi

ng d

ose

to

achie

ve p

re-d

ose

levels

of 1

5-20

μg/

ml m

ay b

e re

quire

d (s

ee

com

men

ts).

Teico

plan

in do

sage

sche

dule

6 m

g/kg

12

hour

ly fo

r 3 d

oses

and

ther

eafte

r onc

e da

ily. H

igher

dose

s, 10

- 12m

g/kg

, in si

milar

dosin

g sch

edule

is

indica

ted in

serio

us in

fecti

ons e

.g.

MRSA

infe

ction

s and

endo

card

itis. S

uch

patie

nts s

hould

be di

scusse

d with

the

clinic

al mi

crobio

logy t

eam.

Must

be ad

minis

tered

slow

ly IV

at a

maxim

um ra

te of

10m

g/mi

n to a

void

reac

tion s

uch a

s red

man

synd

rome

. In

seve

re/c

ompl

icate

d inf

ectio

ns a

lo

ading

dos

e of

25-

30m

g/kg

can

be

used

to fa

cilita

te ra

pid

atta

inmen

t of

targ

et tr

ough

seru

m v

anco

myc

in co

ncen

tratio

n.Co

mplic

ated I

nfec

tions

:1.

Bac

terae

mia

2. En

doca

rditis

3. O

steom

yeliti

s4.

Men

ingitis

5. H

ospit

al Ac

quire

d Inf

ectio

ns ca

used

by

Staph

aure

usCo

mm

ents

Rena

l impa

irmen

t:If

teico

planin

is to

be us

ed, t

he fu

ll dos

e is

given

for t

he fi

rst 4

days

. The

reaf

ter

exten

ded d

osing

inter

vals

are r

equir

ed.

Colle

ct pr

edos

e lev

el be

fore

4th

dose

of

vanc

omyc

in. G

ive th

e dos

e. An

y adju

stmen

tsne

cessa

ry ca

n be m

ade t

o the

5th

dose

onwa

rds.

Pred

ose

level

shou

ld b

e be

twee

n 10

- 15

μg/m

l. (In

seve

re/c

ompl

icate

dinf

ectio

n 15

-20

μg/m

l). If

cont

inuing

va

ncom

ycin

and r

enal

func

tion i

s stab

le, re

peat

level

twice

wee

kly. D

aily l

evels

may

be re

quire

dif

rena

l fun

ction

is un

stable

. Not

e th

at 1

- hou

r po

st d

ose

levels

are

not

nec

essa

ry.

Clear

ly sta

te do

se, t

ime o

f dos

e and

time o

f bloo

d sa

mple

colle

ction

on th

e req

uest

form

.At

wee

kend

s rou

tine a

ssays

are c

arrie

d out

atmi

dday

on Sa

turd

ays a

nd Su

nday

s.

Leve

lsMa

y be r

equir

ed in

certa

in cir

cums

tance

s eg.

endo

card

itis.

Discu

ss wi

th M

icrob

iolog

y tea

m.

Gly

copep

tides

: V

anco

myci

n &

Tei

copla

nin


Dosing Algorithm for VancomycinIs Creatinine Clearance >60ml/min?

CrCl = (140-Age) x Weight (ODW if BMI>30)* (kg) x 1.23 (male) or 1.04 (female)Serum Creatinine (µmol/L)

If patient is anuric (output <500mls/day), treat as per CrCl < 20ml/min

Is the patient seriously ill (signs of severe sepsis)?

Give loading dose 25-30mg/kg (Actual body weight)

Target level is 10-15µg/ml.Is level 10-15µg/ml?

Target level is 15-20µg/ml.Is level 15-20µg/ml?

Pre-dose level resultLevel Dose Recheck alteration pre-dose level5-10 Increase After adjusted each dose dose given and by 500mg before following morning dose**10-15 Increase After adjusted each dose dose given and by 250mg before following morning dose**15-20 Maintain Twice weekly dosing providing renal regimen function is stable**20-25 Reduce After adjusted each dose dose given and by 250mg before following morning dose**>25 Omit next After adjusted dose and dose given and decrease before following each dose morning dose** by 500mg

Prescribe maintenance dose 15mg/kg BD. (Use Actual body weight) (Preferably at 10am, and 10pm to facilitate levels.)

1st level before 4th dose. (Level needs to be PRE-dose)**

Has patient serious infection such as endocarditis, osteomyelitis, bloodstream infecion, meningitis or hospital acquired pneumonia caused by S. aureus?

Give loading dose 15mg/kg (Actual body weight)

CrCl Dose Check 1st level(ml/min) 40-60 15mg/kg od Before 3rd dose**20-40 15mg/kg Before 2nd dose** every 36-48 hrs.<20 15mg/kg Before 2nd dose. every 72-96 hrs. Hold dose until level availableOnce daily doses should preferably be given at 10am to facilitate checking of levels

**Unless renalfunction is

deteriorating orspecifically

advised DOSESSHOULD NOT

BE HELD WHILSTAWAITINGLEVELS

Seek advice from Pharmacy

or Clinical Microbiology if

in doubt

Pre-dose level resultLevel Dose Recheck pre-dose alteration level5-10 Increase After adjusted dose each dose given and before by 250mg following morning dose**10-15 Maintain Twice weekly dosing providing renal regimen function is stable**15-20 Reduce After adjusted dose each dose given and before by 250mg following morning dose**>20 Omit next After adjusted dose dose and given and decrease before following each dose morning dose** by 500mg

*Weight used should be actual body weight (ABW) or for obese patients (BMI>30), an obese dosing weight

(ODW) must be calculated.ODW = IBW + 0.4 (ABW - IBW)

BMI=Weight (kg)/Height (m)²IBW (males) Kg= 50 + (0.9 x no. of cm over 152cm)IBW (females) Kg= 45.5 + (0.9 x no. of cm over 152cm)1 foot = 30.5com, 1 inch = 2.54cm

Yes

Yes

NoYes No

No


Exam

ples

of c

hoice

s of s

witc

h fro

m IV

to o

ral r

oute

“N

ote: O

ral A

ntim

icrob

ials a

re si

gnifi

cant

ly les

s cos

tly th

an in

trave

nous

“

IV

ORA

L

Benz

ylpen

icillin

1.2

-2.4

g 4-6

hr

Amox

icillin

500

mg 8

hrAm

oxici

llin 1

g 6 hr

Co-a

moxic

lav 1

.2g 8

hr

Co-a

moxic

lav 6

25mg

8 hr

Clind

amyc

in 60

0mg 6

hr

Clind

amyc

in 30

0mg 6

hrCli

ndam

ycin

1.2g

6 hr

Cli

ndam

ycin

450m

g 6 hr

Fluclo

xacil

lin 1

- 2

g 6 hr

Flu

cloxa

cillin

500

mg -1

g 6 hr

30 m

inutes

befo

re fo

od

Clarit

hrom

ycin

500m

g 12

hr

Clarit

hrom

ycin

500m

g 12

hr

Metro

nidaz

ole 5

00mg

8 hr

Me

tronid

azole

400

mg 8

hr

Cipro

floxa

cin 4

00mg

12

hr

Cipro

floxa

cin 5

00 -

750

mg 1

2 hr


ANTIMICROBIALS WITH GOOD ORAL BIOAVAILABILITY

*Sanford Guide 2010** Martindale 33rd

edition***Sanford Guide 2010 and Martindale 33rd

edition

Antimicrobial Oral BioavailabilityCiprofloxacin 70%***

Clindamycin 90%*

Fusidic Acid 91%(tablets)*

Fluconazole 90%*

Levofloxacin 98%*

Linezolid 100%*

Metronidazole 99%**


RELATIVE COSTS OF ANTIMICROBIALS*

COST OF ONE WEEK’S SUPPLY OF ANTIMICROBIALSBASED ON NORMAL ADULT DOSE

(antifungals in bold italics)

€0-€10 Flucloxacillin PO, Metronidazole PO, Ciprofloxacin PO, Amoxicillin PO, Co-amoxiclav PO, Clarithromycin PO

€10-€40 Levofloxin PO, Amoxicillin IV, Metronidazole IV Co-amoxiclav IV, Cefuroxime IV, Clindamycin PO, Fusidic acid PO, Fluconazole PO

€40-€60 Piperacillin-Tazobactam IV, Ciprofloxacin IV, Vancomycin IV

€150-€300 Clarithromycin IV, Levofloxacin IV, Rifampicin IV, Meropenem IV, Ceftriaxone IV, Fluconazole IV

€300-€500 Acyclovir IV, Clindamycin IV,

€500-€1000 Linezolid PO & IV

€1000-€3000 Teicoplanin IV, Tigecycline IV

>€3000 Anidulafungin IV, Voriconazole IV, Amphoteracin IV, Caspofungin IV

*Correct at time of publication.


REFERENCES:1. Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. SARI

Hospital Antimicrobial Stewardship Working Group. December 2009.2. Policy on Control and Prevention of Meticillin Resistant Staphylococcus

aureus (MRSA) in Acute Hospitals in the HSE/SE. November 2009.3. Gupta K et al International Clinical Practice Guideline for the treatment of

acute uncomplicated cystitis and pylenephritis in women. 2010 update by IDSA and ESCMID. CID 2011; 52: 103-120.

4. Lim WS, Baudouin SV, George RC et al. BTS Guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009; 64 Suppl 3: iii1-55.

5. Brito V et al. Healthcare - associated pneumonia is a heterogenous disease, and all patients do not need the same broad-spectrum antibiotic therapy as complex nosocomial pneumonia. Current Opinion in Infectious Diseases 2009; 22: 316-325.

6. Masterton. RG et al. Guidelines for the management of hospital acquired pneumonia in the UK. JAC 2008; 62: 5-34.

7. James D. Chalmers, Mudher Al-Khairalla, Philip M. Short, Tom C. Fardon and John H. Winter. Proposed changes to management of lower respiratory tract infections in response to the Clostridium difficile epidemic. J Antimicrob Chemother 2010; 65: 608-618.

8. Policy on Prevention and Control of Clostridium difficile – associated disease In Acute Hospitals HSE/South East. January 2010.

9. Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer, 2010 update by the IDSA. CID 2011; 52(4): e56-e93.

10. Davey et al. Interventions to improve antibiotic prescribing practices for hospital inpatients (review). The Cochrane Library Oct 2008.


HSE South East Acute Hospital Network Antimicrobial Stewardship Group Members

Microbiology Department WRH:

Microbiology SpRs Ext. 2490/8053 Bleep #821 278

Dr. M. Hickey Ext.Dr. M. Doyle Ext.} 2621.2097Dr. B. Carey Ext.Ms. C. Troy, Surveillance Scientist Ext. 2488/2489

Pharmacy Departments.:

WRH Antimicrobial Pharmacist Ext. 2530/2453WGH Antimicrobial Pharmacist Ext. 3261SLKK/Kilcreene Antimicrobial Pharmacist Ext. 5372/5328STGH Antimicrobial Pharmacist Ext. 7119

hse se antibiotic guidelines 2012 booklet

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