Empirical Management of Infection on Critical Care Units at AUH … POLICY v6.pdf · Empirical Management of Infection on Critical Care Units at AUH and RLUH Patricia Crossey (Critical

LIVERPOOL CLINICAL LABORATORIES

Empirical Management of

Infection on Critical Care

Units at AUH and RLUH

Patricia Crossey (Critical Care Pharmacist, RLUH), Alison Hall (ITU Consultant, RLUH), Jenifer Mason (Microbiology Consultant LCL), Robert Parker (ITU

Consultant, AUH) and Clare Sales (Critical Care Pharmacist, AUH)

2017

These Guidelines refer to common ITU presentations and relate to

empirical management only. For indications not covered refer to

the Trust Antibiotic Formulary (Royal and Aintree).

Enquiries to: [email protected] or

[email protected]

https://secure.rlbuht.nhs.uk/sites/Antibiotic/SitePages/HomePage.aspx

http://antibiotic.aintree.nhs.uk/

mailto:[email protected]

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 1

Contents General Principles ............................................................................................................................................................................................. 2

Abdominal Infection .......................................................................................................................................................................................... 3

Non Healthcare associated Intra-abdominal Infection................................................................................................................................. 3

Healthcare associated intra-abdominal infection ........................................................................................................................................ 4

Variceal bleeds and acute liver failure ......................................................................................................................................................... 4

Central Nervous System .................................................................................................................................................................................... 5

Meningitis/Encephalitis ............................................................................................................................................................................... 5

ENT or Dental Infection ..................................................................................................................................................................................... 6

Epiglottitis .................................................................................................................................................................................................... 6

Dental Abscess or other oral infection ......................................................................................................................................................... 6

Respiratory Tract Infection ................................................................................................................................................................................ 7

Community acquired pneumonia ................................................................................................................................................................ 7

Hospital Acquired Pneumonia or Ventilator Associated Pneumonia ........................................................................................................... 7

Aspiration Pneumonia ................................................................................................................................................................................. 8

Infective Exacerbation of Chronic Lung Disease (COPD, bronchiectasis) ..................................................................................................... 8

Suspected influenza with concurrent pneumonia........................................................................................................................................ 8

Sepsis of Unknown Origin.................................................................................................................................................................................. 9

Sepsis of Unknown Origin – Non Neutropenic ............................................................................................................................................. 9

Neutropenic Sepsis ...................................................................................................................................................................................... 9

Skin and Soft Tissue Infection .......................................................................................................................................................................... 10

Necrotising soft tissue infection of any anatomical site ............................................................................................................................. 10

Cellulitis ..................................................................................................................................................................................................... 10

Trauma Prophylaxis ......................................................................................................................................................................................... 11

Prophylaxis in head and neck trauma ........................................................................................................................................................ 11

Prophylaxis for Compound Fractures ......................................................................................................................................................... 11

Selective Decontamination of the Digestive Tract ......................................................................................... Error! Bookmark not defined.

Urosepsis ......................................................................................................................................................................................................... 13

Urosepsis/pyelonephritis ........................................................................................................................................................................... 13

Appendix ......................................................................................................................................................................................................... 14

Infection Control Precautions .................................................................................................................................................................... 14

Weekly Screening ...................................................................................................................................................................................... 15

Notifiable Diseases..................................................................................................................................................................................... 17

Tetanus Prone Wounds .............................................................................................................................................................................. 18

Processing Urgent Specimens Out of Hours (Mon-Fri 1630-0900 and Sat-Sun) ......................................................................................... 19

Gentamicin and Teicoplanin Dosing ........................................................................................................................................................... 21

Gentamicin ........................................................................................................................................................................................... 21

Teicoplanin ........................................................................................................................................................................................... 21

Contact Details ........................................................................................................................................................................................... 21


General Principles 1. Antibiotic treatment should NEVER be delayed in an emergency. However,

wherever possible, microbiological specimens should always be obtained before antibiotic therapy is commenced

2. Prior to antibiotic therapy patients should ALWAYS have TWO sets of blood cultures taken i.e. x2 aerobic and x2 anaerobic bottles. If there are lines present

culture from the line AND a peripheral site. Send other specimens as appropriate

(respiratory, drain fluid, wound swabs etc.)

3. Always check previous Microbiology results, with particular attention to resistant

organisms (see below for common resistance patterns). Note the empirical antibiotic choice

may not cover resistant organisms – please discuss with Microbiology if unsure

4. Antibiotics are not a substitute for source control (i.e. surgical drainage of an abscess)

5. Antibiotics should be administered within 1 hour in patients with signs of severe sepsis or

septic shock

6. Allergy status must be checked BEFORE prescribing and administering any antibiotic and documented on the patient’s drug chart, including where possible the nature of the allergy

7. An antibiotic history should be taken and recorded in the critical care notes 8. All antibiotic prescriptions should have an indication, start date and review or stop date.

9. These guidelines are for empirical management only. Antibiotics should be focussed at the

earliest opportunity on the Microbiology ward round with culture results

10. Do not dose adjust antibiotics in acute kidney injury (including Gentamicin) in the first 24

hours. Following this, and in chronic renal failure seek advice from Pharmacy

Not effective May be effective Effective

Methicillin resistant Staphylococcus aureus (MRSA)

Penicillin, flucloxacillin, co-amoxiclav, tazocin, cephalosporins (except ceftaroline) meropenem

Clarithromycin or clindamycin, doxycycline, trimethoprim

Teicoplanin, linezolid, daptomycin

Vancomycin or glycopeptide resistant Enterococci (VRE or GRE)

Amoxicillin, teicoplanin, tazocin, cephalosporins, meropenem, aminoglycosides, fluoroquinolones

Linezolid, tigecycline, daptomycin

Extended spectrum beta-lactamase producing Enterobacteriaceae AND/OR de-repressed AmpCs (ESBL/AmpC)

Tazocin, co-amoxiclav, cephalosporins, Aztreonam

Aminoglycosides, fluoroquinolones, tigecycline, temocillin

Meropenem, ertapenem

Carbapenemase producing Enterobacteriaceae (CPE)

Tazocin, co-amoxiclav, cephalosporins, meropenem (in isolation)

Fluoroquinolones, aminoglycosides, temocillin, high-dose meropenem (in combination), chloramphenicol, tigecycline, colistin

Always discuss management of suspected CPE infection with an infection specialist


Abdominal Infection

Non Healthcare associated Intra-abdominal Infection

Infection involving ANY intra-abdominal organ (with the exception of kidney) without any of the following:

1. Infection arising >48 hours after admission 2. Presence of invasive surgical device at time of presentation (e.g.

biliary stent) 3. History of infection or colonisation with multi-drug resistant

organism (MRSA, VRE, ESBL, CPE) 4. History of surgery, hospitalisation or dialysis within 12 months of

presentation

Empirical Antibiotics are NOT required in:

Acute-Severe Pancreatitis: Antibiotics are not recommended in the acute phase. In chronic pancreatitis discuss management of all patients with Microbiology.

Bowel ischaemia with no evidence of perforation/peritoneal contamination

Acute gastroenteritis: Antibiotics may be indicated for invasive Salmonella, Shigella or Campylobacter infection – discuss all cases with Microbiology.

Investigations Blood cultures

Intra-operative specimens where appropriate

Recommended Amoxicillin 1g QDS IV, Metronidazole 500mg TDS IV & regular Gentamicin IV1 For oesophageal perforation also include Fluconazole 400mg IV

Alternative (penicillin allergy)

Teicoplanin IV1, regular Gentamicin IV1 & Metronidazole 500mg TDS IV For oesophageal perforation also include Fluconazole 400mg IV

Other notes Duration: In most cases 5-7 days will suffice following complete source control. Post-surgery:

No bacterial contamination of operative field or peritoneum: Consider stopping antibiotics (discuss with Microbiology)

Bacterial contamination of operative field or peritoneum: 5-7 days from definitive operative procedure

Antifungals: With the exception of oesophageal perforation, prophylactic antifungals are not recommended in non-neutropenic ITU patients. Pre-emptive antifungals or targeted therapy to be discussed with Microbiology on individual patient basis


Healthcare associated intra-abdominal infection

Infection involving ANY intra-abdominal organ (with the exception of kidney) with at least one of the following:

1. Infection arising >48 hours after admission 2. Presence of invasive device at time of presentation (e.g. biliary

stent) 3. History of infection or colonisation with multi-drug resistant

organism (MRSA, VRE, ESBL, CPE) 4. History of surgery, hospitalisation or dialysis within 12 months of

presentation

For C. difficile treatments refer to Trust C. difficile policy. Empirical Antibiotics are NOT required in:

Acute-Severe Pancreatitis: Antibiotics are not recommended in the acute phase. In chronic pancreatitis discuss management of all patients with Microbiology.

Bowel ischaemia with no evidence of perforation/peritoneal contamination

Acute gastroenteritis: Antibiotics may be indicated for invasive Salmonella, Shigella or Campylobacter infection – if invasive infection suspected (recent travel, immunocompromised host) discuss with Microbiology


Intra-operative specimens where appropriate

Recommended Tigecycline 100mg STAT then 50mg BD IV & regular Gentamicin IV1 For oesophageal perforation also include Fluconazole 400mg OD IV


Tigecycline 100mg stat, 50mg BD IV & regular Gentamicin IV1 For oesophageal perforation also include Fluconazole 400mg OD IV

Other notes Duration: In most cases 5-7 days will suffice following complete source control. Post-surgery:

No bacterial contamination of operative field or peritoneum: Consider stopping antibiotics (discuss with Microbiology)

Bacterial contamination of operative field or peritoneum: 5-7 days from definitive operative procedure

Tigecycline: Tigecycline is not safe to use in indications other than intra-abdominal infection. If concurrent infection (such as pneumonia) discuss with Microbiology Antifungals: With the exception of oesophageal perforation, prophylactic antifungals are not recommended in non-neutropenic ITU patients. Pre-emptive antifungals or targeted therapy to be discussed with Microbiology on individual patient basis

Variceal bleeds and acute liver failure

Investigations

Recommended Tazocin 4.5g TDS BD IV



Ciprofloxacin 400mg BD IV

Other notes Further advice can be sought from Hepatology or Birmingham Transplant Unit If signs of sepsis: Include regular Gentamicin1

Central Nervous System Meningitis/Encephalitis This is a Notifiable Disease – see appendix

Additional infection prevention precautions are required for suspected meningitis – see appendix


EDTA blood for meningococcal and pneumococcal PCR

CSF: For MC&S and viral PCR +/- meningococcal and pneumococcal PCR, protein and glucose

Urine pneumococcal antigen

HIV test

Recommended Ceftriaxone 2g BD IV AND Acyclovir 10mg/kg IV TDS IV & Dexamethasone IV or PO* If aged over 60 or immunosuppressed: Add Amoxicillin 2g IV every 4 hours


Chloramphenicol 25mg/kg QDS IV + Acyclovir 10mg/kg TDS IV & IV Dexamethasone IV or PO* If aged over 60 of immunosuppressed: Add Co-trimoxazole 30mg/kg IV every 6 hours

Other notes If recent history of travel please discuss with Microbiology *Give IV dexamethasone 10mg QDS IV or PO for 4 days preferably prior to or at the same time as the first dose of antibiotics (if administration delayed dexamethasone may be given up to 12 hours after first dose of antibiotic). Note: Dexamethasone vials contain either 3.3mg or 3.8mg of Dexamethasone depending on the supplier. Suggest using either 9.9mg (3x3.3mg vials) or 9.5mg (2.5x3.8mg vials).

Contact Occupation Health and/or Microbiology regarding prophylaxis for staff members exposed to N. meningitidis


ENT or Dental Infection Epiglottitis

Investigations Throat swab for MC&S

Blood cultures

Recommended Ceftriaxone 2g OD IV


Teicoplanin1 + Ciprofloxacin 400mg BD IV

Other notes

Dental Abscess or other oral infection

If necrotising intra-oral or neck infection suspected contact Microbiology


Intra-operative samples

Recommended Amoxicillin 1g QDS IV + Metronidazole 500mg TDS IV


Clarithromycin 500mg BD IV & Metronidazole 500mg TDS IV

Other notes If necrotising intra-oral or neck infection suspected contact Microbiology


Respiratory Tract Infection Community acquired pneumonia

Onset <48 hours of admission

Suggested Investigations

Blood cultures x 2

Respiratory specimen: BAL>T/asp>sputum

Urinary Legionella and pneumococcal antigen

HIV test

Within flu season (approx. October – March) throat swab for viral PCR

Acute and convalescent sera for atypical pathogens is no longer recommended

Recommended Benzyl-penicillin 2.4g QDS IV & Clarithromycin 500mg BD PO/IV


Teicoplanin IV1 & Clarithromycin 500mg BD PO/IV

Other notes If signs of severe sepsis or septic shock, or the diagnosis of pneumonia is unclear: STAT Gentamicin1

A negative Legionella urinary antigen result does not exclude atypical infection. Continue clarithromycin pending discussion on Microbiology. Assess response to empirical therapy with a Microbiologist at 48-72 hours. If no response or deterioration consideration should be given to changing antibiotics. Gram negative, in particular anti-Pseudomonal cover should be included in patients with structural lung disease (bronchiectasis, CF, long term ventilator). If no prior exposure use ciprofloxacin as an alternative to clarithromycin.

Hospital Acquired Pneumonia or Ventilator Associated Pneumonia

Pneumonia acquired >48 hours of admission to hospital or ventilated patients


Respiratory specimen: BAL>T/asp>sputum

Recommended Benzyl-penicillin 2.4g QDS IV & Flucloxacillin 2g QDS IV & Ciprofloxacin 500mg BD PO or 400mg BD IV If signs of severe sepsis or septic shock: STAT Gentamicin IV1 If MRSA colonised: Teicoplanin1 IV & Ciprofloxacin 500mg BD PO or 400mg BD IV1


If colonised with CPE: discuss with Microbiology


Teicoplanin IV1 & Ciprofloxacin 500mg BD PO or 400mg BD IV If signs of severe sepsis or septic shock: STAT Gentamicin1 If colonised with a CPE: discuss with Microbiology

Other notes

Aspiration Pneumonia

History compatible with aspiration AND signs or symptoms of pneumonia AND minimum of 48 hours post aspiration event. Aspiration of gastric contents or pneumonitis alone is not an indication for antibiotics


Respiratory samples

Recommended Temocillin 2g BD IV & Amoxicillin 1g QDS IV & Metronidazole 500mg TDS IV


Ciprofloxacin 400mg BD IV, Clarithromycin 500mg BD IV & Metronidazole 500mg TDS IV

Other notes

Infective Exacerbation of Chronic Lung Disease (COPD, bronchiectasis)

Check previous respiratory samples – patients with chronic lung disease become colonised with resistant Pseudomonas species.


Respiratory samples

Recommended Benzyl-penicillin 2.4g QDS IV & Ciprofloxacin 500mg BD PO or 400mg BD IV


Teicoplanin1 & Ciprofloxacin 500mg BD PO or 400mg BD IV

Other notes In the case of recent Ciprofloxacin exposure (within the preceding 4-6 weeks): Discuss alternative agent with Microbiology If signs of severe sepsis or septic shock: STAT Gentamicin1

Suspected influenza with concurrent pneumonia

Influenza – like illness with clinical features of pneumonia Additional infection prevention precautions are required for suspected influenza – see appendix


Respiratory samples

Throat swab and viral PCR

Recommended Benzyl-penicillin 2.4g QDS IV & Clarithromycin 500mg BD PO/IV & Flucloxacillin 2g QDS IV & Oseltamivir 75mg BD PO


Teicoplanin IV & Clarithromycin 500mg BD PO/IV & Oseltamivir 75mg BD PO


Other notes If signs of severe sepsis or septic shock: STAT Gentamicin1

Sepsis of Unknown Origin Sepsis of Unknown Origin – Non Neutropenic

Sepsis with no identifiable source. Review with Microbiology at 48 hours is mandatory.

Investigations Blood cultures (including line cultures if appropriate)

Any other appropriate investigations: Wounds, CSU, CSF, respiratory

Recommended Tazocin 4.5g TDS & STAT Gentamicin IV1


Teicoplanin IV1 & Gentamicin IV1 & Metronidazole 500mg TDS IV

Other notes Review at 48 hours with Microbiology is mandatory

Neutropenic Sepsis

Investigations Blood cultures (including line cultures if appropriate)

Any other appropriate investigations: Wounds, CSU, CSF, respiratory

Recommended Tazocin 4.5g TDS IV & STAT Gentamicin IV1 If pulmonary focus: Add Clarithromycin 500mg BD PO/IV If MRSA positive or indwelling line: Add Teicoplanin IV1

If colonised with ESBL or AmpC: Give Meropenem 2g TDS IV If colonised with CPE: Discuss with Microbiology

Alternative (penicillin allergy) – see notes below

Meropenem 2g TDS IV If pulmonary focus: Add Clarithromycin 500mg BD PO/IV If MRSA positive or indwelling line: Add Teicoplanin IV1

If colonised with ESBL or AmpC: Give Meropenem 2g TDS IV If colonised with CPE: Discuss with Microbiology Severe penicillin allergy i.e. anaphylaxis: Discuss risk/benefit ratio

Other notes It is estimated that <1% of patients with penicillin allergy react to carbapenems. In severe penicillin allergy (i.e. anaphylaxis) discuss risks and benefits of carbapenem with Microbiology


Skin and Soft Tissue Infection Necrotising soft tissue infection of any anatomical site

All cases must be referred to Surgical team and discussed with Microbiology urgently This is a Notifiable Disease - see appendix Additional infection prevention precautions are required for suspected invasive Group A streptococcal infections – see appendix


Intra-operative specimens (Urgent Gram stain required)

Wound swabs

Recommended Meropenem 2g IV TDS & Clindamycin 1.2g QDS IV 8 hours +/- IVIG (discuss with Microbiology)


Meropenem 2g IV TDS & Clindamycin 1.2g QDS IV 8 hours +/- IVIG 2g/kg (IVIG administration MUST be discussed with Microbiology)

Other notes Surgical debridement is imperative. Refer all patients to the Surgical Team urgently For details regarding IVIG administration refer to IVIG Policy

Cellulitis Localised cellulitis with no features of necrotising infection

Investigations Blood cultures x2

Skin/wound swab

Recommended Flucloxacillin 2g QDS IV


Teicoplanin IV1 & Clindamycin 300 QDS If high risk of C. difficile: Use Linezolid 600mg BD IV/PO instead of above

Other notes


Trauma Prophylaxis Prophylaxis in head and neck trauma

Prophylaxis is indicated for compound mandibular fractures, soft tissue pre-septal trauma, penetrating orbital injury and pharyngeal-oesophageal injury. Please refer to “Antimicrobial Guidelines for Head and Neck Surgery” for further information All wounds should have a tetanus risk assessment – see appendix

Investigations

Recommended Compound Mandibular Fractures: Chlorhexidine gluconate 0.5% mouthwash BD & Amoxicillin 1g TDS IV & Metronidazole 500mg TDS IV until operation. Soft Tissue pre-septal trauma: IV Flucloxacillin 2g QDS & topical Chloramphenicol 1% ointment TDS Penetrating Orbital Injury: Tazocin 4.5g TDS IV Pharyngeal-oesophageal Injury: Tazocin 4.5g TDS IV (& Teicoplanin IV1 if colonised with MRSA)


Compound Mandibular Fractures: Chlorhexidine gluconate 0.5% mouthwash BD & Clarithromycin 500mg BD IV & Metronidazole 400mg TDS IV until operation Soft Tissue pre-septal trauma: IV Clarithromycin 500mg BD IV & topical Chloramphenicol 1% ointment TDS Penetrating Orbital Injury: Teicoplanin IV1 & Ciprofloxacin 750mg BD IV & Metronidazole 500mg TDS IV Pharyngeal-oesophageal Injury: Teicoplanin IV1 & Ciprofloxacin 750mg BD IV & Metronidazole 500mg TDS IV

Other notes

Prophylaxis for Compound Fractures

All wounds should have a tetanus risk assessment – see appendix

Investigations

Recommended Co-amoxiclav 1.2g IV (alone) TDS, OR Cefuroxime 1.5g IV every 8 hours plus Metronidazole 500mg IV every 8 hours MRSA colonised: Add Teicoplanin 800mg IV 12 hourly for 3 doses DURATION: 48 hours or 24 hours post closure of wound



Clindamycin 600mg IV QDS. Gunshot Injury or very extensive or contaminated wound: Add Ciprofloxacin 400mg IV TDS (or PO 750mg BD) MRSA colonised: Add Teicoplanin 800mg IV BD for 3 doses DURATION: 48 hours or 24 hours post closure of wound

Other notes For tetanus guidance see appendix


Urosepsis Urosepsis/pyelonephritis Sepsis with features in the history or examination that clearly

indicate a renal source. If source of infection is unclear treat as sepsis or unknown origin


MSU or CSU

Recommended Ciprofloxacin 400mg IV BD + STAT Gentamicin IV1


Ciprofloxacin 400mg IV BD + STAT Gentamicin IV1

Other notes Dipstick has poor positive and negative predictive value and should not be used in isolation to diagnose UTI.


Appendix

Infection Control Precautions

Standard precautions should be used for all patients (hand-washing, personal protective equipment

for procedures etc.). Additional precautions required in specific scenarios are outlined below. There

are times when side room availability is limited – in this situation a risk assessment should be

conducted according to local policy. Additional support available if required from IP&C Teams and

Microbiology.

Isolation Required

Isolation Area PPE

MRSA Yes Isolation room Plastic apron and gloves

VRE/GRE Yes (priority if diarrhoea present)

Priority for patients with diarrhoea and uncontrolled leakage of body fluids

Plastic apron and gloves

ESBL or AmpC Yes (priority if diarrhoea present)

Priority for patients with diarrhoea and uncontrolled leakage of body fluids

Plastic aprons and gloves

Clostridium difficile infection + GDH positive

Yes Isolation room Plastic aprons and gloves

CPE Yes Isolation room Surgical gown and gloves

Influenza Yes Isolation room Surgical gown and surgical mask For aerosol generating procedures use FFP3 mask

Suspected or proven invasive Group A streptococcus

Yes – for minimum 48 hours after commencing appropriate antibiotic(s)

Isolation room Plastic aprons and gloves For aerosol generating procedures including intubation use FFP3 mask

Suspected bacterial meningitis

Yes – review at 48 hours with Microbiology results

Isolation room Plastic apron and gloves For aerosol generating procedures including intubation use FFP3 mask

Neutropenic Yes Isolation room Plastic apron and gloves

Inter-Hospital Transfer pending screen results

Yes Isolation room Plastic apron and gloves


Weekly Screening

Patients on ITU should have a multidrug resistant organism (MDRO) screen (rectal & groin AND nose

& throat) for ESBL, AmpC, MRSA, VRE and CPE colonisation on admission and weekly thereafter.

Transfers It is essential that MDRO colonisation status from referring Trust is ascertained prior to transfer.

Refer to local policy regarding isolation. In patients transferred from Aintree ITU, Royal ITU or HDU,

Liverpool Heart and Chest ITU or Walton Centre Horsley ITU consideration may be given to early

removal from side room - discuss with Microbiology or IP&C Team.



Notifiable Diseases

Treating clinicians have a statutory duty to notify the ‘proper officer’ at their local council or local

health protection team (HPT) of suspected cases of certain infectious diseases. Notifiable organisms

will be reported by the laboratory.

To inform Cheshire and Merseyside Health Protection Team:

Mon-Fri 0900-1700: 0344 225 0562 (option 1)

Mon-Fri 1700-0900 or Sat-Sun: Contact the on-call Public Health Doctor via Switch Board at

the Royal (0151 706 2000)

The list below gives common notifiable diseases and is not exhaustive. Please see Health Protection

England website for complete list.

Notifiable Disease Definition/Comment Likely to be Urgent?

Acute encephalitis No

Acute meningitis Viral and bacterial Yes, if bacterial meningitis suspected

Acute hepatitis Yes

Anthrax Suspect in heroin user with severe sepsis, necrotising skin infection or meningitis (especially haemorrhagic meningitis). Typical skin lesion = Painless ulcer with marked oedema and black eschar

Yes

Enteric fever (S. typhoid or paratyphoid)

Fever, constipation, rose spots and recent travel Yes

Food poisoning No – unless associated with a cluster or outbreak

Haemolytic uraemic syndrome Triad of acute renal failure, microangiopathic haemolytic anaemia, and non-immune thrombocytopenia following bloody diarrhoea

Yes

Infectious bloody diarrhoea With or without features of HUS Yes

Necrotising fasciitis (likely to be invasive Group A Streptococcus i.e. in PWID)

Scarlett Fever or suspected invasive infection (i.e. bacteraemia, necrotising fasciitis or septic arthritis)

Scarlet Fever – no Invasive Group A Streptococcal infection – Yes

Legionnaires Disease Pneumonia (usually with extra-pulmonary signs such as headache, abdominal pain, renal failure) AND history of exposure (i.e. cooler units, water, air conditioning, travel history)

Yes

Meningococcal septicaemia Without meningitis for example sepsis with purpuric rash

Yes

SARS Yes

Tetanus Rigidity, muscle spasm and autonomic dysfunction with history of tetanus prone wound or injecting drug use.

Only if associated with injecting drug use

Tuberculosis Clinical picture in keeping with TB and AFB on sputum smear

No – unless suspected cluster, multidrug resistance or healthcare worker

https://www.gov.uk/guidance/notifiable-diseases-and-causative-organisms-how-to-report

https://www.gov.uk/guidance/notifiable-diseases-and-causative-organisms-how-to-report


Tetanus Prone Wounds

A tetanus prone wound is any wound or burn that requires a surgical intervention or when

treatment is delayed for more than 6 hrs, or wounds with any of the following characteristics:

o significant degree of devitalized tissue,

o puncture-type injury (particularly in contact with soil or manure),

o wounds containing foreign bodies, compound fractures,

o wounds or burns in patients who have systemic sepsis.

High risk wounds are those contaminated with material likely to contact tetanus spores i.e. soil,

manure etc.

If the wound or burn fulfils the above criteria and is considered to be high risk then tetanus

immunoglobulin should be given for immediate protection irrespective of the tetanus

immunization history. For further guidance see table below.

Dose: For prevention: 250IU by intramuscular injection, or 500IU if more than 24 hours have elapsed

since injury or there is a risk of heavy contamination or following burns.

Clean Wound Tetanus Prone Wound

Vaccine Vaccine Immunoglobulin

Fully immunised, i.e. has received a total five doses of vaccine at appropriate intervals OR Protetanus Point of Care test demonstrates immunity

None required None required Only if high risk

Primary immunisation complete, boosters incomplete but up to date

A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity)

A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity)

Yes: one dose of human tetanus immunoglobulin in different site

Not immunised or immunisation status not known or uncertain

An immediate dose of vaccine followed, if records confirm that is needed, by completion of a full 5-day dose course to ensure future immunity

An immediate dose of vaccine followed, if records confirm that is needed, by completion of a full 5 dose course to ensure future immunity

Yes: one dose of human tetanus immunoglobulin in different site


Processing Urgent Specimens Out of Hours (Mon-Fri 1630-0900 and Sat-Sun)

The following specimens will be processed urgently out of hours: CSF, joint aspirates, ascitic fluid,

and tissue specimens in suspected necrotising fasciitis. Other specimens may be processed upon

request.

For urgent specimens taken out-of hours:

1) Inform the On-call Microbiology Biomedical Scientist at Royal Liverpool University Hospital

via Switch board (0151 706 2000)

2) Specimen transport to Laboratory:

a. For Royal ITU or HDU: Pod specimen to pod no. 710

b. For Aintree ITU: Take the specimen to Specimen Reception at Aintree (Ground floor

of the main corridor, opposite A&E). The BMS will arrange transport to Liverpool

Clinical Laboratories

3) The on-call BMS or Microbiologist will ring ITU with the result once processed



Gentamicin and Teicoplanin Dosing

Gentamicin

In normal renal function OR acute kidney injury: 5mg/kg STAT max 450mg.

In chronic renal failure: Discuss with Microbiology regarding alternative agents

For regular Gentamicin administration:

o Royal: Take level at 8 hours post dose and refer to the Gentamicin dosing calculator

+/- seek advice from ITU Pharmacist regarding further dosing.

o Aintree: Take a level at 1 hour and 7 hours post dose (if not able to do these take 2

levels approximately 6 hours apart) and refer to the Gentamicin dosing calculator +/-

seek advice from ITU Pharmacist regarding further dosing. Further information

regarding Gentamicin dosing available on the Trust Intranet.

Teicoplanin

Loading regime

Days 1 – 2 12mg/kg BD (rounded to the nearest 200mg vial)

Days 3 – 4 12mg/kg OD (rounded to the nearest 200mg vial)

Take pre-dose (trough) level on day 4

Day 5 onwards Adjust dose according to renal function (see table

2) and review with levels

Maintenance dose (based on renal function)

eGFR > 60ml/min Continue 12mg/kg OD

eGFR 30-60ml/min 6mg/kg OD

eGFR< 30ml/min 4mg/kg OD or 12mg/kg three times a week

Haemodialysis 12mg/kg three times a week after dialysis

Hemofiltration Load as per normal renal function

Contact Details

Microbiology (from RLUH) Ext. 4410

Microbiology (from AUH) Ext. 4900

Pharmacy at RLUH Ext. 2085

Pharmacy at AUH Ext. 3864

http://rlbuhtapps/gdc/

http://ahtpharweb01/epma/gentcalculator.asp

http://antibiotic.aintree.nhs.uk/index.php/home-page/a-z-of-antimicrobial-agents/gentamicin/

Documents

Empirical Management of Infection on Critical Care Units at AUH … POLICY v6.pdf · Empirical Management of Infection on Critical Care Units at AUH and RLUH Patricia Crossey (Critical