Guidelines for the empiric use of antimicrobials in …...Document indication for therapy and intended duration in medical record. Note these guidelines are intended for empiric therapy

Guidelines for the empiric use of antimicrobials in adults

University Hospital WaterfordSouth Tipperary General HospitalKilcreene Orthopaedic HospitalSt. Luke’s General Hospital, KilkennyWexford General Hospital

July 2016

Review Date: July 2017

Acknowledgement: Gentamicin and Vancomycin Algorithims pages 27 & 31 adapted from original algorithims kindly provided by Beaumont/Connolly Hospital Antimicrobial Stewardship Committee in 2014.

Issued in June 2006Revised Annually Revision No 10Review Date July 2017HSE SE Antimicrobial Stewardship Group

Disclaimer:Whilst every effort has been made to ensure the accuracy of the information and material contained in this document, errors or omissions may occur in the content. We acknowledge that new evidence may emerge that may overtake some of these recommendations. The document will be reviewed and revised annually. Prescribers should ensure that the correct drug and dose is prescribed, as is appropriate for each individual patient. References that should be used in conjunction with these guidelines include the British National Formulary (BNF) and the drug data sheets (available on www.medicines.ie). Clinical guidelines are guidelines only and the interpretation and application of the guidelines remains the responsibility of the individual clinician.

Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10

1

Table of Contents Page No. General Guidance 2 - 3Restricted and Reserve Antimicrobials 4MRSA 5 Start Smart Then Focus Care Bundle 6 - 7SepSiS - Evaluation and Management 8Adult Sepsis Management Algorithm (NCEC) 9Septicaemia/Systemic Sepsis, Sepsis in Pregnancy, Neutropenic Sepsis 10 - 11Sepsis Guide 12 - 13Urinary Tract Infection 14Respiratory Tract Infection 15Endocarditis & Intra-abdominal Infections 20 Gastro-intestinal Infection 21Genital Tract Infection 22Bone and Joint Infections 23Skin and Soft tissue Infections 23Central Nervous System 24ENT infections 24 Appendix 1: Start Smart, Then Focus Care Bundle 25Appendix 2: Gentamicin 26 - 27Appendix 3: Amikacin 28 - 29Appendix 4: Glycopeptides: Vancomycin, Teicoplanin 30 - 31Appendix 5: Treatment of Clostridium difficile Infection 32 - 33Appendix 6: Switch from IV to PO 34 - 35Appendix 7: Relative Costs of Antimicrobials 36Appendix 8: Tips on Clinical Assessment of Patients following Notification of Positive Blood Culture and Gram Stain. 37Appendix 9: Guidelines for Consultation with the Clinical Microbiology Advisory Team (C-MAT), University Hospital Waterford 41Appendix 10 : Dose adjustment in renal impairment 42 - 43Appendix 11: Formula for weight calculations 43 - 44Appendix 12: Other guideline documents to consider in association with these guidelines. 45Appendix 13: Penicillin Allergy 46Contact Numbers 47References 48 - 49


2

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

indica

tion f

or th

erap

y and

inten

ded d

urati

on in

med

ical r

ecor

d. No

te the

se gu

idelin

es ar

e inte

nded

for

empir

ic the

rapy

. Rati

onali

se w

hen m

icrob

iolog

y res

ults b

ecom

e ava

ilable

. It is

the

resp

onsib

ility

of th

e pe

rson

/tea

m or

derin

g lab

orat

ory

test

s to

follo

w u

p on

the

resu

lts to

guid

e ap

prop

riate

clini

cal

mana

geme

nt o

f the

pat

ient.

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, l

evofl

oxac

in, so

dium

fusid

ate

and m

etro

nidaz

ole h

ave

exce

llent

ora

l bio

avai

labi

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

shou

ld on

ly be

used

if th

e pati

ent is

not a

bsor

bing

or u

nabl

e to

hav

e or

al m

edica

tions

.

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

3

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 34.

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

ben

zyl p

enici

llin to

PO

amox

icillin

as or

al ab

sorp

tion o

f pen

icillin

is ve

ry po

or.

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 fluo

roqu

inolon

es (e

.g.

levofl

oxac

in an

d cipr

oflox

acin)

, clin

damy

cin an

d cep

halos

porin

s.

11.

Note

that

sodi

um fu

sidat

e ac

id a

nd ri

fam

picin

shou

ld n

ever

be

used

as m

onot

hera

py

12.

Note

on M

acro

lides

(eg e

ryth

romy

cin, c

larith

romy

cin):

This

class

of an

tibiot

ics ha

s a nu

mber

of si

de ef

fects

, int

erac

tions

and c

ontra

indica

tions

that

shou

ld be

take

n int

o acco

unt w

hen p

rescr

ibing

. Cau

tion s

hould

be

parti

cular

ly ex

ercis

ed in

patie

nts w

ith ca

rdiac

histo

ry an

d the

elde

rly.

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

4

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 Hospitals.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 Hospitals Guidelines for use of Reserve and Restricted Antimicrobials for details.

Restricted Antimicrobials *Reserve Antimicrobials IV Piperacillin/Tazobactam IV Cefotaxime IV Ceftazidime IV/PO OfloxacinIV Ceftriaxone IV ColistinIV/PO Ciprofloxacin IV/PO LinezolidIV/PO Levofloxacin IV DaptomycinIV Chloramphenicol IV TigecyclineIV/PO Clindamycin PO FidaxomicinIV Teicoplanin IV CeftarolineIV Vancomycin IV/PO FosfomycinIV Meropenem IV AztreonamIV Amikacin IV Cefazolin IV Ertapenem IV/PO Tedizolid IV/PO Moxifloxacin Antifungals Liposomal Amphotericin B Anidulafungin Caspofungin Voriconazole Posaconazole

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


5

MRSA (Meticillin Resistant Staphylococcus aureus)

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

(Please check patient notes, laboratory results and any currently in use/appropriate Infection Control alerts such as Laboratory SIF code, IPMS Infection Control alert, etc.)

• 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 most recent edition of: Policy on Control and Prevention of Meticillin Resistant Staphylococcus aureus (MRSA) in Acute Hospitals in the HSE/SE for additional information)

If MRSA infection is suspected, consider including a glycopeptide (Vancomycin or Teicoplanin, see page 30-31) in the empiric treatment regimen.

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


6

Day 1: Start Smart... ...then Focus (Day 2 onwards)nwards

Start Smart, Then Focus

7

Day 1: Start Smart... ...then Focus (Day 2 onwards)nwards

Start Smart, Then Focus

8

1 Consider Sepsis

Sepsis =Known or Suspected Infection & Systemic Inflammatory Response Syndrome (SIRS)Defined as the presence of 2 or more of the following:

Temperature >38°C or <36°C

Respiratory Rate >20 breaths per min

PaCo2 <4.3 kPa

Heart Rate >90 beats per min

White Cell Count > 12 or <4

Evaluation and Management of a patient with suspected

Sepsis

3. Assess patient to determine possible Sourcel Urinary Tractl Skin, soft tissue, bone, jointl Abdominal, pelvicl Respiratory Tract infectionl Intravascular catheter or prosthetic devicel Travel historyl Recent antibiotic treatment

2 Intervention - Action within one hour

COMPLETE SEPSIS SIX

1. High Flow Oxygen 4. Urine output measurement

2. Lactate Check 5. CULTURES*

3. Fluid Challenge 6. Antimicrobial Therapy

(*blood, wounds, sputum, urine, CSF, invasive line sites etc. as appropriate)

Source Known Source Unknown

**Refer to relevant section of this guideline for empiric therapy**

ASSESS FOR RISK OF RESISTANT ORgANISmS22 (ref Irish MDRO guidelines)

1. Check MDRO Flag on IPMS/Health Care Record/WRLAB2. Check previous Microbiology results

Stable Unstable - Life Threatening Sepsis

Piperacillin/Tazobactam (Tazocin) 4.5g tds +/- gentamicin *If hypotensive or severe infection add gentamicin, see page 26-27 for dose & monitoring.

PEN ALLERGY: Teicoplanin, Gentamicin, Metronidazole

MRSA See page 5 of guidelines for risk factors for MRSA Add vancomycin (or teicoplanin if patient already on gentamicin), see page 31 for dosing.

Piperacillin/Tazobactam 4.5g tds + amikacin, Refer to page 28-29 for dosing & monitoring of amikacin.

PEN ALLERGY: Teicoplanin, Amikacin, Metronidazole

MRSA See page 5 of guidelines for risk factors for MRSA Add vancomycin (or teicoplanin if patient already on gentamicin), see page 31 for dosing.

5. Refer to Adult Sepsis management Algorithm (Opposite page), NEWS Score & National Sepsis Guidelines14

6. Rationalise antimicrobial therapy when results of Blood cultures and Microbiology results available.


4. Antimicrobial Therapy

9

Adult Sepsis Management Algorithm

Guidance to be read in conjunction with National Clinical Guideline No. 6 Management of Sepsis in Ireland

Further informationwww.health.gov.ie/patient-safety/ncecwww.hse.ie/sepsiswww.hse.ie

** SBP: Systolic Blood Pressure

14

Adult Sepsis Management Algorithm

Hypotension: *MAP ≤ 65mmHG or**SBP < 90mmHgor** SBP decrease > 40mmHG in Adults or < 2 SD below normal for age 14

10

Co

nditi

on

Antib

iotic

Co

mm

ents

Sept

icaem

ia/

Syst

emic

Seps

isAs

sess

patie

nt re

possi

ble fo

cus

of in

fecti

on –

e.g. u

rinar

y tra

ct,

skin/

soft

tissu

e, ab

domi

nal,

ches

t, ne

urolo

gical.

, com

munit

yor

hosp

ital a

cquir

ed, t

rave

lhis

tory,

rece

nt an

tibiot

ic th

erap

y, pr

esen

ce of

pros

theti

c de

vices

, intra

vascu

lar ca

thete

rs,

etc.

Wat

ch fo

r hyp

oten

sion

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 eg

ESBL

, VRE

, CRE

.

Chec

k pre

vious

labo

rator

y res

ults

Ensu

re bl

ood c

ultur

es ta

ken.

See

indiv

idua

l inf

ectio

n tre

atm

ent g

uideli

nes f

or

appr

opria

te th

erap

y. R

efer

to N

EWS S

core

of

the a

dult p

atien

t obs

erva

tion c

hart

and

Seps

is Six

.

Ratio

nalis

e w

ith re

sults

of b

lood

cu

lture

ID a

nd se

nsiti

vitie

s

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)

Penic

illin a

llerg

y: Ge

ntam

icin,

metro

nidaz

ole

plus t

eicop

lanin

Seve

re se

psis

(life

thre

atenin

g) us

e ami

kacin

ins

tead

of g

entam

icin,

espe

cially

if m

ulti-d

rug

resis

tance

susp

ected

. Lev

els m

ust b

e mon

itore

d. (S

ee pa

ge 2

8-29

for d

osing

).

Adap

ted fr

om: H

SE A

dult P

atien

t

Obse

rvati

on Ch

art.

12

See a

lso N

ation

al Se

psis

Guide

line

on pa

ge 1

2 an

d 13.

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

11

Co

nditi

on

Antib

iotic

Co

mm

ents

Neut

rope

nic se

psis9

Pleas

e also

refe

r to

secti

on on

seve

re se

psis

(life

thre

atenin

g) on

pr

eviou

s pag

e

Seps

is in

Preg

nanc

y

Neut

rope

nia =

Neu

troph

il Co

unt <

1.0

Seve

re N

eutro

penia

=

Neut

roph

il Cou

nt <

0.5

Feve

r = Te

mper

ature

> 3

80 C

Refe

r to

Sept

icaem

ia/

Syst

emic

Seps

is on

p10

. Cli

nical

featu

res s

ugge

stive

of

seps

is in

preg

nant

wom

en:

Feve

r/Rig

ors,

Diar

rhoe

a/Vo

mitin

g, Ra

sh, A

bdom

inal/

Pelvi

c Pain

and T

ende

rnes

s, Of

fens

ive Va

ginal

Disch

arge

, Co

ugh,

Urina

ry Sy

mtom

s.11

Initi

al Em

piric

ther

apy:

Pipe

racil

lin-

tazo

bacta

m 4.

5g Q

DS IV

. Add

genta

micin

if

comp

licati

ons (

e.g. h

ypote

nsion

, pne

umon

ia or

an

timicr

obial

resis

tance

susp

ected

or cr

iticall

y ill).

Cons

ider a

dding

vanc

omyc

in or

teico

planin

for sp

ecifi

c clin

ical in

dicati

ons e

.g. su

spec

tedCV

C-rela

ted in

fectio

n or c

ompli

catio

ns as

abov

e.Pe

nicilli

n alle

rgy (

Not S

ever

e rea

ction

/an

aphy

laxis)

: Ceft

azidi

me 2g

TDS I

Vplu

s van

comy

cin or

teico

planin

.Se

vere

reac

tion/

anap

hylax

is to

penic

illin:

Cipro

floxa

cin pl

us ge

ntami

cin pl

ustei

copla

nin

Initi

al e

mpi

rical

ther

apy:

Pipe

racil

lin-ta

zoba

ctam

4.5

g IV

TDS

. Co

nside

r add

ing ge

ntam

icin 3

-5mg

/kg

once

daily

11 (u

se bo

oking

weig

ht) 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 t

eicop

lanin

if pa

tient

is

alrea

dy on

gent

amici

n)Ad

d clin

damy

cin if

inva

sive G

roup

A St

rep

Infe

ction

susp

ected

. Sev

ere s

epsis

(life

th

reate

ning)

use m

erop

enem

1-2

g TDS

.

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

Refe

r to N

EWS/

MEOW

S Sco

re an

d Sep

sis

Six. R

eleva

nt im

aging

stud

ies sh

ould

be

perfo

rmed

prom

tly.

Info

rm Co

nsult

ant O

bstet

rician

Refe

r to

Criti

cal C

are

Team

and

seek

ex

pert

advi

ce fr

om m

icrob

iolo

gist

w

hen

seve

re se

psis

is su

spec

ted.

Re

fer t

o RCO

G Gu

idelin

e: Ba

cteria

l Infe

ction

in

Preg

nanc

y for

furth

er de

tailed

guida

nce.11

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

12

Clinica

l Strat

egy an

d Prog

ramme

s Divis

ion

A

IS SE

PSIS

SUSP

ECTE

D?

NEWS

≥ 4 (

5 on s

upple

menta

ry O 2)

ARE A

NY 2

OR M

OREM

ODIFI

EDSIR

S CRIT

ERIA

PRES

ENT?

I f Yes

: THI

S IS S

EPSIS

S

SEPS

IS SIX

– AIM

TOCO

MPLE

TE W

ITHIN

1 HOU

R

Look

for s

igns o

f orga

n dys

functi

on:

SEVE

RE SE

PSIS

An

y orga

n dys

functi

on: T

HIS I

S SEV

ERE S

EPSIS

R egis

trar o

r Con

sulta

nt to

review

imme

diatel

y.

A

Look

for s

igns o

f sep

tic sh

ock

(follo

wing

admi

nistra

tion o

f fluid

bolus

)

SEPT

IC SH

OCK

If eith

er pr

esen

t: THI

S IS S

EPTIC

SHOC

KCr

itica

l car

e con

sult r

equir

ed

Clinica

l Strat

egy an

d Prog

ramme

s Divis

ion

A

IS SE

PSIS

SUSP

ECTE

D?

NEWS

≥ 4 (

5 on s

upple

menta

ry O 2)

ARE A

NY 2

OR M

OREM

ODIFI

EDSIR

S CRIT

ERIA

PRES

ENT?

If Yes

: THI

S IS S

EPSIS

S

SEPS

IS SIX

– AIM

TOCO

MPLE

TE W

ITHIN

1 HOU

R

Look

for s

igns o

f orga

n dys

functi

on:

SEVE

RE SE

PSIS

An

y orga

n dys

functi

on: T

HIS I

S SEV

ERE S

EPSIS

Regis

trar o

r Con

sulta

nt to

review

imme

diatel

y.

A

Look

for s

igns o

f sep

tic sh

ock

(follo

wing

admi

nistra

tion o

f fluid

bolus

)

SEPT

IC SH

OCK

If eith

er pr

esen

t: THI

S IS S

EPTIC

SHOC

KCr

itica

l car

e con

sult r

equir

ed

13

14

Urina

ry Tr

act

Infe

ction

s³Lo

wer

urin

ary

tract

infec

tion

(unc

ompli

cated

)/UT

I in fe

males

.

Hosp

ital a

cquir

ed o

r re

curre

nt U

TI o

rco

mpl

icate

d UT

I/UT

I in

men

.

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

days

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.

Penic

illin a

llerg

y; ge

ntam

icin (

see p

age 2

6 fo

r dos

ingre

gimen

) and

revie

w at

48 ho

urs.

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,

use c

o-am

oxicl

av

(If no

t alle

rgic

to pe

nicilli

n (dis

cuss

if ne

eded

))In

preg

nanc

y nitr

ofur

antoi

n may

also

be us

ed

but it

shou

ld be

avoid

ed at

term

.

Patie

nts w

ith re

curre

nt U

TIs m

ay ha

vere

sistan

t org

anism

s. Us

e 7-

10 d

ays

treat

men

t in

mal

es.

Send

bloo

d cult

ures

and M

SU. R

atio

nalis

eth

erap

y as

soon

as p

ossib

le. C

heck

cu

lture

and

ant

imicr

obia

l sen

sitiv

ity

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 the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

15

COM

MU

NIT

Y A

CQU

IRED

PN

EUM

ON

IA

Base

d o

n “B

ritis

h Th

oraci

c So

ciet

y gui

del

ines

for

the

mana

gem

ent

of

com

mun

ity a

cqui

red p

neum

onia

in a

dul

ts: U

pdate

2009.”

4

Thes

e gu

idel

ines

are

not

aim

ed a

t: (a

) Pat

ient

s w

ith k

now

n pr

edisp

osin

g co

nditi

ons

such

as

canc

er o

r im

mun

osup

pres

sion

adm

itted

with

pn

eum

onia

to s

peci

alis

t uni

ts s

uch

as o

ncol

ogy,

hae

mat

olog

y, p

allia

tive

care

, inf

ectio

us d

iseas

e un

its

or 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 “ch

est i

nfec

tions

”

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 the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

16

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

Legi

onell

osis

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

) Disc

uss w

ith M

icrob

iolo

gist

.

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 the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

17

CURB6

5 s

core

New

ons

et m

enta

l con

fusio

nU

rea>

7 m

mol

/LRe

spira

tory

rate

≥ 3

0/m

inSy

stol

ic b

lood

pre

ssur

e <9

0mm

Hg

and/

ordi

asto

lic b

lood

pre

ssur

e ≤6

0mm

Hg

Age

≥65

yea

rs

Low

risk

0 or

1 p

oint

Inte

rmed

iate

risk

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

omm

ended

the

rapy

for

Com

mun

ity A

cqui

red P

neum

onia

(Tak

en fr

om J

Ant

imic

rob

Che

mot

her 2

012;

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 the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

18

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 (in

cludi

ng

aspi

ratio

n pn

eum

onia

)Wi

thin 4

days

of ad

missi

on

& no

rece

nt an

tibiot

ics:

More

than

4 da

ys si

nce

admi

ssion

:

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

19.

Co-a

moxic

lav 62

5mg T

DS PO

or 1.

2g TD

S IV

for 8

days

.Pe

nicilli

n alle

rgy (

NOT I

gE m

ediat

ed re

actio

n/a

naph

ylaxis

): Ce

furo

xime 7

50 m

g -1.

5g TD

S IV.

(add

me

tronid

azole

in as

pirati

on pn

eumo

nia).

Seve

re Ig

E med

iated

reac

tion/

anap

hylax

is to

penic

illin:

Levo

floxa

cin 5

00mg

PO /

IV O

D. (1

2 ho

urly

if se

vere

). (a

dd

metro

nidaz

ole in

aspir

ation

pneu

monia

).

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

9.Pe

nicilli

n alle

rgy:

if NO

T IgE

me

diated

/ana

phyla

xis an

d if p

neum

onia

is no

t sev

ere c

onsid

er

cefuro

xime 1

.5g TD

S IV.

(add m

etron

idazo

le in

aspira

tion p

neum

onia)

.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

). (a

dd m

etron

idazo

le in

aspir

ation

pneu

monia

).

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 16.

If pa

tient

is co

nsid

ered

to b

e hig

h ris

kfo

r MRS

A, co

nsid

er a

dding

Va

ncom

ycin.

De-e

scal

ate

base

d on

cultu

re re

sults

w

here

pos

sible.

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

19

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

orith

m f

or h

ealth

care

-ass

ocia

ted p

neum

onia

(H

CAP)

the

rapy*

HCA

P pre

sent

: Pat

ient

from

nur

sing

hom

e/ch

roni

c ca

re fa

cilit

y, re

cent

hos

pita

lizat

ion

Ass

ess se

veri

ty o

f ill

ness

(Use

CU

RB65

sco

re)

AN

D

Pres

ence

of r

isk fa

ctor

s fo

r mul

ti-dr

ug re

sista

nt (M

DR)

pat

hoge

ns(a

ntib

iotic

s in

pas

t 6 m

onth

s, h

ospi

taliz

atio

n in

pas

t 3 m

onth

s, p

oor f

unct

iona

l sta

tus,

imm

une

supp

ress

ion)

Seve

re p

neum

onia

(Bas

ed o

n C

URB

65 s

core

)

No

(CU

RB65

sco

re m

ild o

r mod

erat

e)Ye

s (C

URB

65 s

core

3 o

r >)

0-1

Risk

s fo

r MD

RTr

eat f

or c

omm

onC

AP

Path

ogen

sSe

e C

AP

p.17

≥1 R

isk fo

r MD

RTr

eat f

or M

DR

Path

ogen

sSe

e H

AP

p.18

≥2 R

isks

for M

DR

Trea

t for

MD

R Pa

thog

ens

See

HA

P p.

18

0 Ri

sks

for M

DR

Trea

t as

seve

re C

AP

See

CA

P p.

17

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

20

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

Cons

ider a

dditio

n of g

entam

icin i

f uns

table

In se

vere

seps

is: Ta

zocin

+/-

Gen

tamici

n

Cons

ider 7

-10

day c

ourse

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 +

/- te

icopla

nin

Discu

ss wi

th M

icrob

iolog

y tea

m as

soon

as

possi

ble

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

21

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

.

Refe

r to

Appe

ndix

5 a

t bac

k of

boo

klet

.

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

Refe

r to C

. diffi

cile a

lgorit

hm on

page

32.

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

22

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 500

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 26

- 27)

+ 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

. (Do

xycy

cline

is co

ntra

indica

ted

in pr

egna

ncy)

Cons

ider t

reati

ng pa

rtner.

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

23

Co

nditi

on

Antib

iotic

Co

mm

ents

Bone

and

Joint

Infe

ction

s

*Prop

hylax

is of

open

frac

ture -

se

e loc

al ort

hopa

edic

protoc

ols

avail

able

in su

rgica

l prop

hylax

is gu

idelin

es an

d ED

Dept.

*Diab

etic f

oot in

fectio

ns /

OM

cons

ult lo

cal/

natio

nal g

uideli

nes.

Skin

and

soft

tissu

e In

fecti

ons

Oste

omye

litis

/ Se

ptic

arth

ritis

Cellu

litis,

ery

sipela

s

Susp

ecte

d Se

vere

/Inv

asive

Gr

oup

A St

rep

Infe

ction

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 so

dium

fusid

ate as

abov

e. Se

vere

IgE m

ediat

ed re

actio

n/an

aphy

laxis

to pe

nicilli

n: Va

ncom

ycin

plus s

odium

fusid

ate

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

reacti

on/a

naph

ylaxis

): Ce

furox

ime 7

50mg

-1.5g

TDS

Seve

re Ig

E med

iated

reac

tion/

anap

hylax

isto

penic

illin:

Clind

amyc

in 1.

2g Q

DS IV

.(+

Vanc

omyc

in if

seve

re ce

lluliti

s)

Treat

as N

ecro

tising

fasc

itis,

see

belo

w

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

1.2g

QDS

+/- g

enta

mici

n.

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

10 da

ys m

inimu

m.

NOTE

: sev

ere

cellu

litis

shou

ld n

ot b

etre

ated

with

clar

ithro

myc

in).

If MR

SA su

spec

ted us

e van

comy

cin.

If Gr

oup A

Stre

p Inf

ectio

n con

firme

d, co

nside

r de-e

scalat

ion to

IV be

nzylp

enici

llin

plus c

linda

mycin

, foll

owing

discu

ssion

with

Mi

crobio

logist

.

Modif

y tre

atmen

t acco

rding

to M

icrob

iolog

y re

sults

and c

linica

l res

pons

e.

Penic

illin a

llerg

y: Do

xycy

cline

100

mg B

D PO

plu

s metr

onida

ziole

400m

g TDS

PO23

If se

vere

discu

ss wi

th m

icrob

iolog

y tea

m.G

uide

lines

for t

he e

mpi

ric u

se o

f ant

imic

robi

als

in a

dults

HSE

SE

Hos

pita

ls Ju

ly 2

016

Inde

x no

ASG

001

Dat

e of

App

rova

l Jul

y 20

16, R

evisi

on D

ate

July

201

7, R

evisi

on n

o 10

24

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) or

seve

re in

fecti

on su

spec

ted ad

d va

ncom

ycin

until

sens

itivitie

s con

firme

d. Tre

at fo

r 14

days

if pn

eumo

coccu

s. Tre

at fo

r 7 da

ys

if me

ningo

coccu

s. Se

vere

IgE m

ediat

ed re

actio

n/an

aphy

laxis

to pe

nicilli

n: ch

loram

phen

icol 1

g IV

QDS.

If im

muno

comp

romi

sed a

dd va

ncom

ycin

and

co-tr

imox

azole

.

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. (Se

e pag

e 42)

Requ

est H

SV PC

R on

CSF.

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 50

0mg

BD PO

for 1

0 da

ysSe

nd th

roat

swab

Penic

illin a

llerg

y: Cla

rithr

omyc

in 50

0mg B

DPO

for 5

-7 da

ys

Gui

delin

es fo

r the

em

piric

use

of a

ntim

icro

bial

s in

adu

lts H

SE S

E H

ospi

tals

July

201

6In

dex

no A

SG 0

01 D

ate

of A

ppro

val J

uly

2016

, Rev

ision

Dat

e Ju

ly 2

017,

Rev

ision

no

10

25

Da

y 1

: S

tart

Sm

art

...

...t

he

n F

oc

us (

Da

y 2

on

wa

rds)

nw

ard

s

Sta

rt S

ma

rt,

Th

en

Fo

cu

sA

ppen

dix

1:

Start

Sm

art

, Th

en F

ocus

Care

Bun

dle

.

26

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 2

7 fo

r dos

ing al

gorit

hm.

Endo

card

itis:

3mg/

kg on

ce da

ily

Note

exclu

sions

, plea

se di

scuss

with

Mi

crobio

logy T

eam.

and s

ee al

gorit

hm p2

7No

te: D

ivide

d dos

es pr

efered

to on

ce da

ily do

sing i

n the

follo

wing

cases

: •

Endo

card

itis ca

sed by

HAC

Ek or

ganis

ms•

Pros

thetic

Valve

Endo

card

itis•

Enter

ococ

cal E

ndoc

ardit

is(Li

st ma

y not

be ex

haus

tive -

discu

ss ca

se wi

th mi

crobio

logy t

eam)

.

Preg

nanc

y:

3-5m

g/kg

once

daily

Pleas

e disc

uss w

ith m

icrob

iolog

y tea

m if

need

ed an

d see

algo

rithm

p27.

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 27

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.

***C

learly

state

dose

, tim

e of d

ose a

nd tim

e of b

lood

samp

le co

llecti

on on

the r

eque

st fo

rm. *

**

Appen

dix

2: O

nce

daily

Am

inog

lyco

side

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

hlor

ide

0.9

% o

ver

30

-60

min

utes

.


27Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016

Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10

Adult Gentamicin Once Daily Dosing Guideline 1. Select patient appropriately

● Cautions : Endocarditis, pregnancy, renal replacement therapies, in Cystic Fibrosis & patients with severe burns. ● Consider patient factors associated with potential toxicity prior to prescribing Gentamicin e.g. underlying renal function, hearing

difficulty, and concurrent nephrotoxic drugs. ● Contraindicated in myasthenia gravis. ● Review need to continue Gentamicin beyond 7 days. Increased risk of nephrotoxicity beyond 7 days treatment. If to continue

rationale should be documented.

3. Check a trough level 16-18 hours after FIRST dose ● Monitor U&Es ensure patient is well hydrated and monitor creatinine as gentamicin is nephrotoxic. ● Ensure sample is labelled with the date & time of the last dose and the date & time level was taken. E.g. 4pm dosing=8 -10am level,

6pm dosing=10am-12noon level

4. Trough level Action <1µg/ml In range

Continue current regimen.

>1µg/ml Level is High

Check the time dose was given and sample taken. Was level taken at 16-18 hours after dose?

If trough level >1µg/ml and <2µg/ml and treatment still indicated then consider holding the dose until the level is <1µg/ml and reducing the dose by 1mg/kg. Discuss with Pharmacy if required.

If trough >2µg/ml and treatment still indicated seek advice from Pharmacy.

5. Repeat trough level when clinically indicated Creatinine normal Twice Weekly

Creatinine abnormal or deteriorating Daily or alternate days

2. Prescribe dose ● If weight> 120% IBW use obese dosing weight (ODW) to

calculate gentamicin dose ● Maximum dose 500mg daily ● If anuric (<500mls/day), treat as CrCl <10ml/min.

CrCl (ml/min) Dose

>80 5mg/kg

50-80 4mg/kg

30-50 3mg/kg

10-30 2mg/kg

<10 1-2mg/kg redose when level <1µg/ml

Calculating the dose

Weight used should be actual body weight (ABW), or for obese patients (Weight ≥ 120% IBW) an obese dosing weight (ODW) must be calculated.

For formula (see appendix 13 page 43)

Dose should never exceed 500mg daily

















CrCl (ml/min) Dose

>80 5mg/kg

50-80 4mg/kg

30-50 3mg/kg

10-30 2mg/kg






















CrCl (ml/min) Dose

>80 5mg/kg

50-80 4mg/kg

30-50 3mg/kg

10-30 2mg/kg






Twice weekly gentamicin trough level

Daily or alternate day gentamicin level

















CrCl (ml/min) Dose

>80 5mg/kg

50-80 4mg/kg

30-50 3mg/kg

10-30 2mg/kg






Adult Gentamicin Once Daily Dosing Guideline

28

App

endi

x 3

: Am

inog

lyco

side

s –

Am

ikac

in d

osin

g gu

idel

ines

Once

dai

ly d

osing

Dosin

g Sc

hedu

leM

onito

ring

and

Leve

lsCo

mm

ents

Refe

r to

Algo

rithm

pa

ge 2

9

lM

onito

r U&E

s ens

ure

patie

nt is

well

hyd

rate

d an

d m

onito

r cre

atini

ne a

s am

ikac

in is

neph

roto

xic.

lT

ROUG

H (i.

e. P

re-D

ose)

leve

ls re

quire

d. N

o ne

ed fo

r Pea

k lev

els.

lF

irst T

ROUG

H (P

re-d

ose)

leve

l to

be ta

ken

just

prio

r to

the

seco

nd.18

lTa

rget

TRO

UGH

(Pre

-dos

e) le

vel ≤

5mg/

L15

lE

nsur

e sa

mpl

e is

labe

lled

with

the

date

& ti

me

of th

e la

st d

ose

and

the

date

& ti

me

level

was

take

n.

lA

mik

acin

is a

rest

ricte

d an

timicr

obia

l and

shou

ld o

nly b

e pr

escri

bed

for t

he

treat

men

t of i

nfec

tions

due

to g

enta

mici

n re

sista

nt G

ram

neg

ativ

e ba

cilli

or if

re

com

men

ded

by a

cons

ultan

t micr

obio

logi

stlS

tand

ard

Once

dai

ly re

gim

en is

not

suita

ble

in en

doca

rditi

s15, c

ystic

fibr

osis19

, as

cities

19, m

ajor

bur

ns19

, feb

rile

neut

rope

nia15

, men

ingiti

s15, t

uber

culo

sis, o

r pr

egna

ncy15

. Use

mult

iple

daily

dos

ing se

e pa

ge 2

9.lC

onsid

er re

nal f

uncti

on, h

ydra

tion

stat

us a

nd co

ncom

itant

nep

hrot

oxic

med

icine

slT

hera

peut

ic Dr

ug M

onito

ring

is ne

cess

ary

to p

reve

nt to

xicit

y no

tabl

y ne

phro

toxi

city

& ot

otox

icity

.lR

isk o

f oto

toxi

city

incre

ases

with

hig

her c

umula

tive

dose

s and

long

er tr

eatm

ent

cour

ses.

lC

ontra

-indi

cate

d in

mya

sthe

nia g

ravi

s.15

Mult

iple

daily

dos

ingDo

sing

Sche

dule

Mon

itorin

g an

d Le

vels

Com

men

tsRe

fer t

o Al

gorit

hm

pg 2

9

lM

onito

r U&E

s ens

ure

patie

nt is

well

hyd

rate

d an

d m

onito

r cre

atini

ne a

s am

ikac

in is

neph

roto

xic.

lT

ROUG

H (i.

e. P

re-D

ose)

leve

ls re

quire

d. Ta

ke

TROU

GH le

vel i

mm

edia

tely

pre

-dos

e.18

Tar

get

Trou

gh Le

vel ≤

10m

g/L

lP

EAK

levels

requ

ired.

Take

PEA

K lev

el on

e ho

ur

post

dos

e. Ta

rget

Pea

k Le

vel ≤

30m

g/L18

lIn

itial

ly ta

ke P

EAK

& TR

OUGH

leve

ls ar

ound

th

e th

ird/f

ourth

dos

e. T

hen

take

TRO

UGH

(Pre

-dos

e) le

vels

ever

y 48

hrs

or m

ore

if re

nal

func

tion

is un

stab

le/im

paire

d. M

onito

r Pea

k lev

els O

nce

wee

kly.

lE

nsur

e sa

mpl

e is

labe

lled

with

the

date

& ti

me

of th

e la

st d

ose

and

the

date

& ti

me

level

was

take

n.

lA

mik

acin

is a

rest

ricte

d an

timicr

obia

l and

shou

ld o

nly b

e pr

escri

bed

for t

he

treat

men

t of i

nfec

tions

due

to g

enta

mici

n re

sista

nt G

ram

neg

ativ

e ba

cilli

or if

re

com

men

ded

by a

cons

ultan

t micr

obio

logi

stlM

ultip

le Da

ily D

osing

dai

ly re

gim

en is

to b

e us

ed fo

r ind

icatio

ns o

f end

ocar

ditis

, cy

stic

fibro

sis, a

sciti

es, m

ajor

bur

ns, f

ebril

e ne

utro

penia

, men

ingiti

s or p

regn

ancy

. lT

hera

peut

ic Dr

ug M

onito

ring

is ne

cess

ary

to p

reve

nt to

xicit

y no

tabl

y ne

phro

toxi

city

& ot

otox

icity

.lR

isk o

f oto

toxi

city

incre

ases

with

hig

her c

umula

tive

dose

s and

long

er tr

eatm

ent

cour

ses.

lC

ontra

-indi

cate

d in

mya

sthe

nia g

ravi

s.15

29

App

endi

x 3

: Am

inog

lyco

side

s –

Am

ikac

in d

osin

g gu

idel

ines

Once

dai

ly d

osing

Dosin

g Sc

hedu

leM

onito

ring

and

Leve

lsCo

mm

ents

Refe

r to

Algo

rithm

pa

ge 2

9

lM

onito

r U&E

s ens

ure

patie

nt is

well

hyd

rate

d an

d m

onito

r cre

atini

ne a

s am

ikac

in is

neph

roto

xic.

lT

ROUG

H (i.

e. P

re-D

ose)

leve

ls re

quire

d. N

o ne

ed fo

r Pea

k lev

els.

lF

irst T

ROUG

H (P

re-d

ose)

leve

l to

be ta

ken

just

prio

r to

the

seco

nd.18

lTa

rget

TRO

UGH

(Pre

-dos

e) le

vel ≤

5mg/

L15

lE

nsur

e sa

mpl

e is

labe

lled

with

the

date

& ti

me

of th

e la

st d

ose

and

the

date

& ti

me

level

was

take

n.

lA

mik

acin

is a

rest

ricte

d an

timicr

obia

l and

shou

ld o

nly b

e pr

escri

bed

for t

he

treat

men

t of i

nfec

tions

due

to g

enta

mici

n re

sista

nt G

ram

neg

ativ

e ba

cilli

or if

re

com

men

ded

by a

cons

ultan

t micr

obio

logi

stlS

tand

ard

Once

dai

ly re

gim

en is

not

suita

ble

in en

doca

rditi

s15, c

ystic

fibr

osis19

, as

cities

19, m

ajor

bur

ns19

, feb

rile

neut

rope

nia15

, men

ingiti

s15, t

uber

culo

sis, o

r pr

egna

ncy15

. Use

mult

iple

daily

dos

ing se

e pa

ge 2

9.lC

onsid

er re

nal f

uncti

on, h

ydra

tion

stat

us a

nd co

ncom

itant

nep

hrot

oxic

med

icine

slT

hera

peut

ic Dr

ug M

onito

ring

is ne

cess

ary

to p

reve

nt to

xicit

y no

tabl

y ne

phro

toxi

city

& ot

otox

icity

.lR

isk o

f oto

toxi

city

incre

ases

with

hig

her c

umula

tive

dose

s and

long

er tr

eatm

ent

cour

ses.

lC

ontra

-indi

cate

d in

mya

sthe

nia g

ravi

s.15

Mult

iple

daily

dos

ingDo

sing

Sche

dule

Mon

itorin

g an

d Le

vels

Com

men

tsRe

fer t

o Al

gorit

hm

pg 2

9

lM

onito

r U&E

s ens

ure

patie

nt is

well

hyd

rate

d an

d m

onito

r cre

atini

ne a

s am

ikac

in is

neph

roto

xic.

lT

ROUG

H (i.

e. P

re-D

ose)

leve

ls re

quire

d. Ta

ke

TROU

GH le

vel i

mm

edia

tely

pre

-dos

e.18

Tar

get

Trou

gh Le

vel ≤

10m

g/L

lP

EAK

levels

requ

ired.

Take

PEA

K lev

el on

e ho

ur

post

dos

e. Ta

rget

Pea

k Le

vel ≤

30m

g/L18

lIn

itial

ly ta

ke P

EAK

& TR

OUGH

leve

ls ar

ound

th

e th

ird/f

ourth

dos

e. T

hen

take

TRO

UGH

(Pre

-dos

e) le

vels

ever

y 48

hrs

or m

ore

if re

nal

func

tion

is un

stab

le/im

paire

d. M

onito

r Pea

k lev

els O

nce

wee

kly.

lE

nsur

e sa

mpl

e is

labe

lled

with

the

date

& ti

me

of th

e la

st d

ose

and

the

date

& ti

me

level

was

take

n.

lA

mik

acin

is a

rest

ricte

d an

timicr

obia

l and

shou

ld o

nly b

e pr

escri

bed

for t

he

treat

men

t of i

nfec

tions

due

to g

enta

mici

n re

sista

nt G

ram

neg

ativ

e ba

cilli

or if

re

com

men

ded

by a

cons

ultan

t micr

obio

logi

stlM

ultip

le Da

ily D

osing

dai

ly re

gim

en is

to b

e us

ed fo

r ind

icatio

ns o

f end

ocar

ditis

, cy

stic

fibro

sis, a

sciti

es, m

ajor

bur

ns, f

ebril

e ne

utro

penia

, men

ingiti

s or p

regn

ancy

. lT

hera

peut

ic Dr

ug M

onito

ring

is ne

cess

ary

to p

reve

nt to

xicit

y no

tabl

y ne

phro

toxi

city

& ot

otox

icity

.lR

isk o

f oto

toxi

city

incre

ases

with

hig

her c

umula

tive

dose

s and

long

er tr

eatm

ent

cour

ses.

lC

ontra

-indi

cate

d in

mya

sthe

nia g

ravi

s.15

Adult Amikacin Dosing Guideline

1. Select patient appropriately Consider once daily dosing (except for indications for multiple daily dosing on page 28).

2. Prescribe dose based on Patient’s – Weight, Height, BMI & Renal Function CHECK & DOCUMENT: Weight, Height, Renal Function (CrCl) before prescribing dose Maximum dose 1.5g daily (Maximum cumulative dose 15g15 ) If weight > Ideal Body Weight (IBW), Dose is based on IBW.

See indications p28.

If weight is < IBW use actual body weight Obese patients (weight >120% IBW), use ODW.

For formula for weight calculation see appendix 11, page 43-44

MULTIPLE DAILY DOSING 17

Renal Function CrCl ml/min

Dose

> 50ml/min 7.5mg/kg every 12 hours 20-50 ml/min 5-6mg/kg every 12 hours

10-20ml/min 3-4mg/kg every 24 hours <10ml/min 2mg/kg every 24-48 hours

ONCE DAILY DOSING 16

Renal Function CrCl ml/min

Dose

> 80ml/min

60-80 ml/min

40-60 ml/min

30-40 ml/min

20-30ml/min

< 20 ml/min

3. Monitor Renal function and Carryout Therapeutic Drug Monitoring

ONCE DAILY DOSING

4. Take Trough level then give the next dose (provided patient is not at risk of nephrotoxicity). Check the trough level result before giving the SECOND dose. (See page 28 for guidance on monitoring and levels) Trough level Action ≤ 5mg/L15 In range

● Continue current regimen. Provided renal function is stable. Monitor level every 3-5 days.

> 5mg/L15 Level is High

●Check when level was taken – level taken <18hrs post dose are not true trough levels. ● If it is a true trough level then omit next dose, re-assay in 24 hrs. & check U&Es ● Re-dose if clinically indicated when levels fall ≤5mg/L but extend dosing interval accordingly for subsequent doses depending on the creatinine clearance - discuss appropriate reduced dose with pharmacist.

MULTIPLE DAILY DOSING

4. Interpretation of Therapeutic Drug Monitoring Troughs & Peaks (See page 28 for guidance on monitoring and levels) Trough level Action ≤ 10mg/L15 In range

Continue current dose regimen. Provided renal function is stable and continued administration is required, monitor levels twice weekly.


Ensure the level was taken at the correct time. If a true pre-dose level omit any further doses. Re-check renal function and review need for further amikacin treatment. If further advice is needed contact pharmacy.

Peak level Action ≤ 30mg/L15 In range

Continue current regimen. Provided dose & renal function is stable and continued administration is required, monitor peak levels once weekly.


Check level taken at correct time. Contact pharmacy for advice on further management.

15mg/kg daily12mg/kg daily

7.5mg/kg daily4mg/kg daily

7.5mg/kg every 48 hours Multiple Daily Dosing Recommended


30

Adult VANCOMYCIN Dosing Guideline

1. Select patient appropriately ■ Renal

Renal

& ototoxicity has been associated with use of vancomycin. ■ Monitoring of serum levels is a necessity. ■ Administer at a rate not greater than 10mg/min.

2. Prescribe dose

Actual body weight is used to calculate all doses unless weight >120% IBW use obese dosing weight-

see

calculations as per Appendix 13page 43-44.

CrCl Dose (Round to nearest 50mg)

> 60ml/min 15mg/kg BD

30 – 60 ml/min 15mg/kg OD

15 – 30 ml/min 15mg/kg every 48hrs

< 15 ml/min or dialysis

15mg/kg day 1. Only re-dose at 15mg/kg when trough level in target range. Hold dose until level available

■ Maximum Single Dose 2g ■ If anuric, output<500mls/day, treat as CrCl < 15ml/min

3. Take FIRST trough level BEFORE 4th dose. Trough must be measured PRE-DOSE (or within one hour prior to administering dose)

Doses are NOT to be held whilst awaiting levels unless renal function deteriorating or speci�ically advised

4. Ascertain target level. Standard target level is 10-15mg/L but if patient has a serious infection such as endocarditis, osteomyelitis, bloodstream infection, meningitis or hospital-acquired pneumonia caused by S.aureus, target level is 15-20mg/L.

5. Check trough level result and adjust dose accordingly Target level 10-15mg/L Target Level 15-20mg/L Level (mg/L)

Dose alteration Recheck pre-dose level Level (mg/L)

Dose alteration Recheck pre-dose level

<5# Increase each dose by 500mg

After adjusted dose given and before following morning dose*



5-10 Increase each dose by 250mg




10-15 Maintain dosing regimen

Twice weekly, providing renal function is stable*


Twice weekly providing renal function is stable*

15-20 Reduce each dose by 250mg




>20 Omit next dose and decrease each dose by 500mg




* Doses are NOT to be held whilst awaiting levels unless renal function is deteriorating or speci�ically advised # If persistently sub-therapeutic levels, consult pharmacy or microbiology for advice

6. Check serum creatinine regularly ■ Ensure patient well hydrated. ■ If renal function stable (& level in target range), twice weekly levels are suf�icient ■ If renal function unstable, check trough level more frequently (e.g. daily or alternate days)

Initial Dose: Prescribe initial loading dose of 25mg/kgMaximum single dose 2g

Maintenance Dose: see table below

Va

ncom

ycin

Dosa

ge S

ched

ule

Leve

ls Co

mm

ents

Refe

r to

dosin

g al

gorit

hm p

age

31.

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

. A

load

ing d

ose

of 2

5mg/

kg w

ill

facil

itate

rapi

d at

tainm

ent o

f ta

rget

trou

gh se

rum

van

com

ycin

conc

entra

tion.

Espe

cially

impo

rtant

in

com

plica

ed in

fecti

ons s

uch

as:

1. B

acter

aemi

a2.

Endo

card

itis3.

Oste

omye

litis

4. M

ening

itis5.

Hos

pital

Acqu

ired I

nfec

tions

caus

ed by

Sta

ph au

reus

Com

men

tsRe

nal im

pairm

ent:

If tei

copla

nin is

to be

used

, the

full d

ose

is giv

en fo

r the

first

4 da

ys. T

here

after

ex

tende

d dos

ing in

terva

ls ar

e req

uired

.(se

e also

appe

ndix

10 pa

ge 4

2).

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

.

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.

App

endi

x 4

: Gly

cope

ptid

es: V

anco

myc

in &

Tei

copla

nin


31

Adult VANCOMYCIN Dosing Guideline

1. Select patient appropriately ■ Renal

Renal

& ototoxicity has been associated with use of vancomycin. ■ Monitoring of serum levels is a necessity. ■ Administer at a rate not greater than 10mg/min.

2. Prescribe dose

Actual body weight is used to calculate all doses unless weight >120% IBW use obese dosing weight-

see

calculations as per Appendix 13page 43-44.

CrCl Dose (Round to nearest 50mg)

> 60ml/min 15mg/kg BD

30 – 60 ml/min 15mg/kg OD

15 – 30 ml/min 15mg/kg every 48hrs

< 15 ml/min or dialysis

15mg/kg day 1. Only re-dose at 15mg/kg when trough level in target range. Hold dose until level available

■ Maximum Single Dose 2g ■ If anuric, output<500mls/day, treat as CrCl < 15ml/min

3. Take FIRST trough level BEFORE 4th dose. Trough must be measured PRE-DOSE (or within one hour prior to administering dose)

Doses are NOT to be held whilst awaiting levels unless renal function deteriorating or speci�ically advised

4. Ascertain target level. Standard target level is 10-15mg/L but if patient has a serious infection such as endocarditis, osteomyelitis, bloodstream infection, meningitis or hospital-acquired pneumonia caused by S.aureus, target level is 15-20mg/L.

5. Check trough level result and adjust dose accordingly Target level 10-15mg/L Target Level 15-20mg/L Level (mg/L)

Dose alteration Recheck pre-dose level Level (mg/L)

Dose alteration Recheck pre-dose level










Twice weekly, providing renal function is stable*


Twice weekly providing renal function is stable*









* Doses are NOT to be held whilst awaiting levels unless renal function is deteriorating or speci�ically advised # If persistently sub-therapeutic levels, consult pharmacy or microbiology for advice

6. Check serum creatinine regularly ■ Ensure patient well hydrated. ■ If renal function stable (& level in target range), twice weekly levels are suf�icient ■ If renal function unstable, check trough level more frequently (e.g. daily or alternate days)

Initial Dose: Prescribe initial loading dose of 25mg/kgMaximum single dose 2g

Maintenance Dose: see table below


contact pharmacy for advice

32

32 Updated CDI guidelines February 2013

Figure R2: CDI disease severity stratification and general and specific treatment measures for initial episode of CDI and first recurrence.(29)

Please refer to BNF for children or local paediatric formulary for doses of metronidazole and vancomycin for paediatric patients.

INITIAL EPISODE OF CDI OR FIRST RECURRENCE General Measures:

• Adequate replacement of fluid and electrolytes • Immediately discontinue unnecessary antimicrobial therapy • Avoid antimotility medications • Review other risk factors for CDI • Review proton pump inhibitor use • Appropriate infection prevention and control to include patient isolation with Contact Precautions and

appropriate hand washing.

Mild to Moderate CDI: • No features of severe CDI

• Oral or nasogastric metronidazole 400 mg TDS for 10 to 14 days. (Grade A)

• Inability to take oral medication: intravenous (IV) metronidazole 500mg TDS for 10 to 14 days. (Grade D)

• Metronidazole intolerance or contraindication: oral vancomycin 125mg QDS for 10 to 14 days. (Grade A)

• * Oral fidaxomicin 200mg BD for 10 days may be an alternative to metronidazole(Grade C/D) or vancomycin (Grade A) in patients aged 16 yrs and older but only following discussion with a clinical microbiologist or specialist ID consultant.

• Monitor closely for deterioration/progression to severe CDI

Severe CDI:(Suggested by any of the following) • Clinical: fever, rigors, abdominal pain • Laboratory: Leucocytosis of ≥15,000

cells/µL , or rise in serum creatinine of ≥50% above baseline or serum creatinine >133 µmol/L).

• Endoscopic findings: pseudo membranous colitis

• Early surgical opinion • Oral vancomycin 125 mg, QDS

for 10 to 14 days. (Grade A) • *Oral fidaxomicin 200mg BD

for 10 days may be an alternative to vancomycin (Grade A) in patients aged 16 yrs and older but only following discussion with a clinical microbiologist or specialist infectious diseases consultant.

Severe, complicated CDI:Severe disease with:

• Hypotension • Shock • Rising serum lactic acid levels • Ileus • Mega colon

• Early surgical opinion • Vancomycin 500 mg, oral or

nasogastric QDS and metronidazole 500mg, IV TDS (Grade D)

• Consider Intracolonic vancomycin 500 mg, four to six times daily if ileus present or suspected (Grade D)

Adapted From Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland Update of 2008 Guidance HPSC 2013

Appendix 5: Treatment of Clostridium difficile Infection

13


33

34 Updated CDI guidelines February 2013

7. How do you manage second and subsequent recurrences and what do you do if a

patient keeps getting recurrences? • Management of second and subsequent recurrences of CDI is summarised in Figure R3. • Consider supervised trial of anti‐motility agents alone if post‐infective irritable bowel

syndrome is suspected after more than 20 days of anti‐C. difficile treatment (only if patient has a normal white cell count and no abdominal symptoms or signs of severe CDI). (Grade D)

Figure R3: Management of Multiple Recurrences of CDI

First episode of recurrent CDI

Severity assessment, general measures and specific anti‐CDI therapy as outlined on page 32

• Review all anti‐microbial therapy and other medications. Ensure adequate fluid and electrolytes and review nutritional status. (Grade D)

• Contact clinical microbiologist or specialist infectious diseases consultant expert for advice

• Consider the following options after expert advice as above: • Oral Vancomycin tapering/pulse therapy (Grade D):

o 125mg 6 hourly for 7 days o 125 mg 12 hourly for 7 days o 125 mg daily for 7 days o 125 mg every other day for 7 days o 125 mg every 3 days for 7 days

or • Oral Fidaxomicin 200mg BD for 10 days (Grade D) or • Oral Vancomycin 125mg QDS for 10 days followed by a chaser of oral

rifaximin 400mg TDS for 20 days (Grade B) or • Intravenous immunoglobulin therapy 150‐400mg/kg per day for 1 to

3 doses (Grade D) or • Faecal microbiota transplantation (Grade A)

Second and subsequent episodes of recurrent CDI

Adapted From Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland Update of 2008 Guidance HPSC 2013


34

ANTIMICROBIALS WITH GOOD ORAL BIOAVAILABILITY

*Sanford Guide 2014** Martindale 33rd

edition***Sanford Guide 2014 and Martindale 33rd

edition

Oral switch – consider when patient is afebrile and infection parameters are settling for 48 hours and normal oral absorption. Generally NOT appropriate in meningitis, endocarditis, febrile neutropenia or acute osteomyelitis/septic arthritis.

Antimicrobial Oral BioavailabilityCiprofloxacin 70-80%***Clindamycin 90%*Sodium Fusidate 91%(tablets)*Fluconazole 90%*Levofloxacin 99%*Linezolid 100%*Metronidazole 99%**


Appendix 6: IV to PO Switch

35

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

Le

voflo

xacin

500

mg -

24hr

/12h

r Le

voflo

xacin

500

mg -

24hr

/12h

rCe

furo

xime 7

50mg

- 1.

5 g T

DS 8

hr

Co-a

moxic

lav 6

25mg

8 hr

In Pe

nicilli

n Alle

rgy d

iscus

s with

Micr

obiol

ogist


36

Appendix 7: Relative Costs of Antimicrobials*


Relative Costs of AntimicrobialsCOST OF ONE WEEK’S SUPPLY OF ANTIMICROBIALS BASED ON

NORMAL ADULT DOSE (antifungals in bold italics)€0-€10 Flucloxacillin PO, Metronidazole PO, Ciprofloxacin PO,

Amoxicillin PO, Co-amoxiclav PO, Clarithromycin PO, Doxycycline PO, Levofloxacin PO

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

€40-€60 Gentamicin IV, Benzypenicillin IV, Piperacillin-Tazobactam IV, Vancomycin IV

€100-€300 Colistin IV, Meropenem IV, Clarithromycin IV, Rifampicin IV, Amikacin IV, Ceftriaxone IV, Aciclovir IV, Aztreonam IV, Cefazolin IV (Unlicensed), Fosfomycin PO

€300-€500 Clindamycin IV, Ertapenem IV, Linezolid PO & IV€500-€1000 Ceftazidime IV, , Ceftaroline IV, Fosfomycin IV,

Tigecycline IV

€1000-€3000

Daptomycin IV, Teicoplanin IV, Fidaxomicin PO, Anidulafungin IV, Voriconazole PO

>€3000 Voriconazole IV, Amphotercin IV, Caspofungin IV

37

Appendix 8: Tips on Clinical Assessment of Patients Following Notification of

Positive Blood Culture and Gram Stain.

Gram Positive Cocci (GPC)Perhaps the most common gram stain result phoned during the working day or after hours.Potential GPC organisms (most common):Staphylococci (Staphylococcus aureus (MSSA or MRSA) or Coagulase Negative Staphylococci)Staphylococci often have an appearance of cells in groups or clusters on gram.Streptococci (Including Group A streptococci or other haemolytic streptococci e,g Group B/C/G, Enterococci (including Ent Faecalis / Ent faecium / VRE if either resistant to vancomycin) Streptococcus pneumoniae, (pneumococcus), Streptococcus viridans.Streptococci often have an appearance of cells in pairs or chains on gramRisk assessment The key is to review the patient carefully for signs and symptoms of sepsis / bacteraemia. Carry out a NEWS score and follow the Sepsis Six protocol if clinically indicated. Bear in mind that the gram stain result may reflect a causative organism of life threatening sepsis ( e,g MSSA, MRSA, Group A Strep, Streptococcus pneumoniae, Enterococcus spp ) or a skin contaminant (e.g Coag Neg Staph / Strep viridans) , therefore careful clinical risk assessment is paramount. Note it is important not to dismiss potential skin contaminants such as Coagulase Neg Staph / Strep viridans if endocarditis / intravascular catheter or prosthetic device infection suspected. Empiric Antibiotic CoverThis should be guided by the gram stain appearance and likely significance / pathogen based on the clinical risk assessment. Consult the current empiric antimicrobial guideline document for advice on empiric cover in the relevant section. Check previous microbiology results and for a history of MRSA colonisation / infection. If the potential pathogen appears likely from the likely source of sepsis ensure patient is on appropriate antimicrobial therapy for that source and pathogen ( e.g Group A Strep in severe soft tissue infection / Strep pneumoniae in CAP).If systemic sepsis suspected, and source and potential pathogen unclear - glycopeptides cover most gram positive organisms and a stat dose of vancomycin is a reasonable option to cover the patient pending the culture result of ID and sensitivity. It is critically important however that this step is taken only if clinical indication of sepsis or significant infection and that the antimicrobial treatment is later reviewed with the culture ID and sensitivity and assessed re need to continue / stop / change therapy.If the patient is clinically well following a thorough clinical review and contamination is suspected – a watch- and-observe approach is reasonable pending ID and sensitivity on culture. Ensure there is a trigger for a repeat review and initiation of empiric antimicrobial therapy if the patient develops new signs/symptoms.


Relative Costs of AntimicrobialsCOST OF ONE WEEK’S SUPPLY OF ANTIMICROBIALS BASED ON

NORMAL ADULT DOSE (antifungals in bold italics)€0-€10 Flucloxacillin PO, Metronidazole PO, Ciprofloxacin PO,

Amoxicillin PO, Co-amoxiclav PO, Clarithromycin PO, Doxycycline PO, Levofloxacin PO

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

€40-€60 Gentamicin IV, Benzypenicillin IV, Piperacillin-Tazobactam IV, Vancomycin IV

€100-€300 Colistin IV, Meropenem IV, Clarithromycin IV, Rifampicin IV, Amikacin IV, Ceftriaxone IV, Aciclovir IV, Aztreonam IV, Cefazolin IV (Unlicensed), Fosfomycin PO

€300-€500 Clindamycin IV, Ertapenem IV, Linezolid PO & IV€500-€1000 Ceftazidime IV, , Ceftaroline IV, Fosfomycin IV,

Tigecycline IV

€1000-€3000

Daptomycin IV, Teicoplanin IV, Fidaxomicin PO, Anidulafungin IV, Voriconazole PO

>€3000 Voriconazole IV, Amphotercin IV, Caspofungin IV

38

Gram Negative Bacilli (GNB)

Gram negative bacilli on gram of blood culture represents presumptive gram negative septicaemia and the need for urgent review and prompt antibiotic treatment pending confirmation of ID.

Potential GNB organisms (most common):Enterobacteriaciae including E-coli, Klebsiella,Enterobacter spp, Pseudomonas, Acinetobacter spp, gram negative anaerobes including bacteroides (less common)Note that MDRO (Multi-Drug Resistant Organism) including ESBL E-coli/Klebisella, CRE E coli/Klebsiella, MDR Pseudomonas / Acinetobacter are included in this category

Risk assessment The key is to review the patient carefully for signs and symptoms of sepsis / bacteraemia. Carry out a NEWS score and follow the Sepsis Six protocol if clinically indicated. Bear in mind that the gram stain result of GNB may reflect a causative organism of life threatening sepsis and may harbour antibiotic resistance mechanisms. Ensure Sepsis Protocols are followed as clinically appropriate.In a very small number of cases GNB on blood culture may turn out to be contaminants (e.g some Acinetobacter / environmental GNBs) but the vast majority are clinically significant and often pathogens of life-threatening sepsis, warranting immediate appropriate antibiotic therapy and source control.

Empiric Antibiotic CoverGram negative sepsis requires urgent review and appropriate empiric antibiotic therapy.Consult this document for advice on empiric cover in the relevant section. If the potential pathogen appears likely from the likely source of sepsis ensure patient is on appropriate antimicrobial therapy for that source and pathogen. If source unclear – see section on Septicaemia / Systemic Sepsis – Unknown source on P.6 of this guideline.

Gram Negative Cocci (GNC)

Gram negative cocci on gram of blood culture represents presumptive Meningococcal Septicaemia and is a medical emergency warranting urgent senior clinical review, supportive therapy and rapid administration of appropriate empiric antimicrobials pending confirmation of ID. Notify Public Health.

The key is to review the patient urgently for signs and symptoms of meningococcal sepsis. The patient may already be on appropriate empiric therapy following the initial clinical assessment if meningococcal sepsis was suspected. Carry out a NEWS score and follow the Sepsis Six protocol if clinically indicated. Ensure Meningococcal Sepsis Protocols are followed and that the patient is on the appropriate antimicrobials and doses.See relevant section in this guideline.


39

Gram Positive Bacilli (GPB)

Potential GPB organisms later confirmed by culture:“Diphtheroid” bacilli or CoryneformsProprionibacteriaBacillus speciesListeria monocytogenes/sppAnaerobic GPB including Clostridium perfringens and other Clostridia species

Risk assessment The key is to review the patient carefully for signs and symptoms of sepsis / bacteraemia. Carry out a NEWS score and follow the Sepsis Six protocol if clinically indicated. Bear in mind that the gram stain result may reflect a causative organism of life threatening sepsis ( e,g Listeria / Clostridia species) or more frequently, a skin contaminant (e,g Diphtheroid bacilli or Bacillus species), therefore careful clinical risk assessment is paramount. It is important not to dismiss potential skin contaminants such as Diphtheroid bacilli / Bacillus species if endocarditis / intravascular catheter or prosthetic device infection suspected, or if the more uncommon conditions such as Diphtheria / Bacillus anthracis / Bacillus cereus infection suspected on clinical grounds.

Empiric Antibiotic CoverThis should be guided by the gram stain appearance and likely significance / pathogen based on the clinical risk assessment. If Listeria bacteraemia / sepsis suspected – Amoxicillin +/- Gentamicin (Penicillin allergy - use Vancomycin)If Clostridial bacteraemia / sepsis suspected (e.g in setting of faecal peritonitis / severe wound infection etc) – a broad – spectrum penicillin such as co-amoxiclav / piperacillin – tazobactam + metronidazole (in penicillin allergy discuss with microbiology team).If systemic sepsis suspected, and source unclear - glycopeptides cover most gram positive organisms and a reasonable option to cover the patient pending ID and sensitivity and follow up with culture and review of antimicrobial therapy.However if the patient is clinically well following a thorough clinical review and contamination is suspected, – a watch-and-observe approach is reasonable pending ID and sensitivity on culture. Bear in mind that the patient may already be on appropriate antibiotic regimen for their condition. Ensure there is a trigger for a repeat review and initiation of empiric antimicrobial therapy if the patient develops new signs/symptoms.


40

Yeasts on gram stain

Yeasts on gram stain should be considered as significant and suggestive of candidaemia ( candida blood stream infection) pending full clinical review and subsequent species identification.Assess the patient for signs and symptoms of candidaemia, carry out a NEWS score and review previous microbiology results for history of candida colonisation.

Review with regards to potential source(s) including intravenous catheters.

Empiric antifungal cover Start an echinocandin such as anidulafungin 200mg stat IV followed by 100mg OD IV pending subsequent identification of the candida species and antifungal sensitivity testing. Liaise with clinical microbiology team regarding follow up and assessment for potential de-escalation to fluconazole as part of the clinical review the following day, and for advice on ongoing management such as source control and optimisation of antifungal therapy based on antifungal sensitivity testing and clinical response.

Note on Appendix 8:Please note that this guide is not comprehensive of all potential pathogens and scenarios for positive blood cultures. It is a simply a guide to aid the attending doctor when assessing the clinical significance and need for urgent action on receipt of a new blood culture gram stain result (verbal / electronic).All empiric therapy should be modified according to definitive ID and sensitivity testing, clinical response and senior consultation.

Each individual case should be taken on its own merits and the clinical assessment of the patient and actions, including prescribing of empiric antimicrobial therapy for newly positive blood cultures remains the responsibility of the attending clinician.

41

Appendix 9: Guidelines for Consultation with the Clinical Microbiology Advisory Team (C-MAT)

University Hospital WaterfordThe On-Duty Clinical Microbiology Advisory Team (C-MAT) can be contacted on the contact numbers on page 40 (9.30 - 5.30 Monday to Friday). A consultant out-of-hours-service is available for urgent clinical advice outside of these hours. Prior to contacting the team please have the following 3 actions completed:1. Review the Guidelines for Empiric Use of Antimicrobials in Adults 2014 – many queries including empiric

therapy by condition, treatment algorithms and therapeutic drug monitoring can be answered here.2. Ensure the patients’ previous microbiology results have been reviewed and summarised and available for

the consultation.3. Provide the C-MAT team member with an ISBAR summary – please see below

C-MAT Consultation Modified ISBAR

Identify1.Yourself, 2. Patient, Name, MRN, DOB, Ward

SituationSummarise main issues related to sepsis / infectionInclude other relevant key issues in presenting complaint

Backgound LOS in hospitalLead up to this point – course in hospital, procedures done and dates, relevant test resultsCurrent antimicrobial therapy

AssessmentOutline relevant details of your clinical assessment– general impression, signs and symptoms, temp, BP, NEWS score etcLaboratory findings – e.g WCC, CRP, Lactate, Renal fx , Liver fx, Other as relevantImaging results if available and relevant ( Echo, CT, MRI, Bone Scan, Other )Results of other relevant investigations available / pending

Recommendations Based on this consultation, accurately document the further recommendations from the C-MAT team which may include for example:

l Further tests- -Micro (blood cultures, swabs, fluids, tissue, stool, sputum, urine, serology, CSF, other) -Lab WCC ,CRP, Lactate, U/E, LFTs, antibiotic drug levels, Other) -New / Further Imaging ( Echo, CT, MRI, Bone Scan, Other )

l Antimicrobial therapy -Recommendations on antimicrobial therapy, choice of agent(s), dose optimisation, proposed length of treatment.



Appendix 10: Antimicrobial Dose Adjustment in Patients with Renal impairment

microbial Dose Adjustment in Pa ents with Renal impairment

***SEE NOTES ON OPPOSITE PAGE***

microbials where no dose adjustment is necessary (in adults)

Amphotericin iv (liposomal)15,17,20,21 Chloramphenicol iv17 Fusidic acid po/iv15,17

Anidulafungin iv15,17,20,21 Clindamycin iv15,17,20,21 Metronidazole po/iv15,17,21

Caspofungin iv15,17,20,21 Doxycycline po15,17,20,21

xone iv17,20,21 **Trimethoprim may cause hyperkalaemia in pa ents with renal impairment

microbial Mild Renal Impairment (GFR 20-50mls/min)

Moderate Renal Impairment (GFR 10-20mls/min)

Severe Renal Impairment (GFR <10mls/min)

Aciclovir iv

GFR 25-50mls/min 5-10mg/kg q12h17,21

GFR 10-25 mls/min 5-10mg/kg q24h17,21

2.5-5mg/kg q24h17,21

Amoxicillin

Dose as in normal renal fun on17


250mg-1g q8h (max 6g in 24h in endocard 17

Benzylpenicillin


600 mg – 2.4 g q6h depending on severity of infec on17


Cefuroxime iv

Dose as in normal renal function

750mg-1.5g q12h17 750mg-1.5g q 24h17

Ciprofloxacin


10-30ml/min 50-100% of normal dose

50% of normal dose (100% dose may be given for short periods under exc onal circumstances)17

Clarithromycin

GFR 30-50mL/min Dose as in normal renal fun on17

GFR 10-30mL/min Oral: 250-500mg q12h IV: 250-500mg q12h17

Oral: 250-500mg q12h IV: 250-500mg q12h17

Co-amoxiclav


GFR 10-30ml/min IV: 1.2g q12h Oral: Dose as in normal renal fun on17

IV:1.2g stat followed by 600mg q8h or 1.2g q12h Oral: Dose as in normal renal fun on17

Flucloxacillin



Dose as in normal renal fun on up to a total daily dose of 4g17

Fluconazole Reduce dose by 50%15 Levofloxacin

In l dose 250-500mg

In l dose 250-500mg then 125mg q12-24h17

In l dose 250-500mg then 125mg 12-48 hourly.

Meropenem 500mg-2g q12h17,21

500mg-1g q12h or 500mg q8h17,21

500mg-1g q24h17,21

Nitrofurantoin Contraindicated17 Contraindicated17 Contraindicated Piperacillin/ Tazobactam (TAZOCIN®)

Dose as in normal renal fun on17,21

4.5g q12h,

4.5g q12h

Teicpolanin

Give normal loading dose, then 200-400mg q48-72h17

Trimethoprim** Dose as in normal renal fun on17

GFR <15 give 50-100% of dose.17 GFR <15 give 50-100% of dose.17

17

50-100% of normal dose

then 125-250mg 12-24 hourly


GFR (mL/min): 40-60Dose as in normal renal function, then reduce dose after 4th day to200mg daily or 400mg every 48H

GFR (mL/min): <40Dose as in normal renal function, then reduce dose after 4th day to30% of the dose daily or 400mg every 72H

This table is for guideline purposes only and correct at time of publication (July 2016)Consult most up-to-date SPC / renal drug database before prescribing.

(26-50ml/min) (10-25ml/min)or 1gTDS

43

Antimicrobial Dose Adjustment in Patients with Renal impairment

This table includes many of the antimicrobials recommended within these guidelines but is not exhaustive. Vancomycin, Gentamicin & Amikacin, please see relevant algorithms. For advice on an antimicrobial not listed, please contact pharmacy.

The majority of the published information available on dosing recommendations in renal impairment is based on the traditional Cockcroft and Gault estimation of creatinine clearance (CrCl). 2. Estimated Glomerular Filration Rate (eGFR) provided by the Modification of Diet in Renal Disease trial (MDRD) is now routinely used as a guide to renal impairment and is reported by biochemistry . eGFR is an estimate of GFR only. Creatinine must be stable (eGFR may be unreliable in acutely ill patients). eGFR is not valid in pregnancy, children or at extremes of body type (high or low BMI). Multiply eGFR by 1.21 for Black race. For advice on antimicrobial prescribing in patients on renal replacement therapy or peritoneal dialysis and

transplant patients please contact pharmacy or dialysis unit/consultant nephrologist.

For usual dose consult current BNF/SPC

FORMULA FOR RENAL FUNCTION CALCULATION CrCl = ( 140 – age) x weight (kg) x K Serum Cr(micromoles/L)

● K = 1.23 for males and 1.04 for females ● Weight = actual weight (use ODW* if obese SEE BOX with Formulae for weight calculations) ● If patient is anuric or intermittent dialysis, treat as CrCl < 10ml/min

FORMULAE FOR WEIGHT CALCULATIONS


● If actual weight > Ideal Body Weight (IBW) Dose is based on IBW

● If actual weight is < IBW use actual body weight

IBW (kg) = R+ (2.3kg X every inch over 5ft) R=50 for males and 45.5 for females

Obese patients (weight >120% IBW) use Obese Dosing Weight (ODW)ODW *(kg) = IBW+0.4 (Actual weight-IBW)

BMI = weight (kg)/height (m)2 see page 44

1 foot = 30.5cm 1 inch = 2.54cm

Antimicrobial Dose Adjustment in Patients with Renal impairment

This table includes many of the antimicrobials recommended within these guidelines but is not exhaustive. Vancomycin, Gentamicin & Amikacin, please see relevant algorithms. For advice on an antimicrobial not listed, please contact pharmacy.

The majority of the published information available on dosing recommendations in renal impairment is based on the traditional Cockcroft and Gault estimation of creatinine clearance (CrCl). 2. Estimated Glomerular Filration Rate (eGFR) provided by the Modification of Diet in Renal Disease trial (MDRD) is now routinely used as a guide to renal impairment and is reported by biochemistry . eGFR is an estimate of GFR only. Creatinine must be stable (eGFR may be unreliable in acutely ill patients). eGFR is not valid in pregnancy, children or at extremes of body type (high or low BMI). Multiply eGFR by 1.21 for Black race. For advice on antimicrobial prescribing in patients on renal replacement therapy or peritoneal dialysis and

transplant patients please contact pharmacy or dialysis unit/consultant nephrologist.

For usual dose consult current BNF/SPC

FORMULA FOR RENAL FUNCTION CALCULATION CrCl = ( 140 – age) x weight (kg) x K Serum Cr(micromoles/L)

● K = 1.23 for males and 1.04 for females ● Weight = actual weight (use ODW* if obese SEE BOX with Formulae for weight calculations) ● If patient is anuric or intermittent dialysis, treat as CrCl < 10ml/min



● If actual weight > Ideal Body Weight (IBW) Dose is based on IBW

● If actual weight is < IBW use actual body weight

IBW (kg) = R+ (2.3kg X every inch over 5ft) R=50 for males and 45.5 for females

Obese patients (weight >120% IBW) use Obese Dosing Weight (ODW)ODW *(kg) = IBW+0.4 (Actual weight-IBW)

BMI = weight (kg)/height (m)2 see page 44

1 foot = 30.5cm 1 inch = 2.54cm

Appendix 11: Formulae For Weight Calculation

15,21

microbial Dose Adjustment in Pa ents with Renal impairment

***SEE NOTES ON OPPOSITE PAGE***

microbials where no dose adjustment is necessary (in adults)

Amphotericin iv (liposomal)15,17,20,21 Chloramphenicol iv17 Fusidic acid po/iv15,17

Anidulafungin iv15,17,20,21 Clindamycin iv15,17,20,21 Metronidazole po/iv15,17,21

Caspofungin iv15,17,20,21 Doxycycline po15,17,20,21

xone iv17,20,21 **Trimethoprim may cause hyperkalaemia in pa ents with renal impairment

microbial Mild Renal Impairment (GFR 20-50mls/min)

Moderate Renal Impairment (GFR 10-20mls/min)

Severe Renal Impairment (GFR <10mls/min)

Aciclovir iv

GFR 25-50mls/min 5-10mg/kg q12h17,21

GFR 10-25 mls/min 5-10mg/kg q24h17,21

2.5-5mg/kg q24h17,21

Amoxicillin



250mg-1g q8h (max 6g in 24h in endocard 17

Benzylpenicillin




Cefuroxime iv

Dose as in normal renal function

750mg-1.5g q12h17 750mg-1.5g q 24h17

Ciprofloxacin


10-30ml/min 50-100% of normal dose

50% of normal dose (100% dose may be given for short periods under exc onal circumstances)17

Clarithromycin


GFR 10-30mL/min Oral: 250-500mg q12h IV: 250-500mg q12h17

Oral: 250-500mg q12h IV: 250-500mg q12h17

Co-amoxiclav


GFR 10-30ml/min IV: 1.2g q12h Oral: Dose as in normal renal fun on17

IV:1.2g stat followed by 600mg q8h or 1.2g q12h Oral: Dose as in normal renal fun on17

Flucloxacillin



Dose as in normal renal fun on up to a total daily dose of 4g17

Fluconazole Reduce dose by 50%15 Levofloxacin

In l dose 250-500mg

In l dose 250-500mg then 125mg q12-24h17

In l dose 250-500mg then 125mg 12-48 hourly.

Meropenem 500mg-2g q12h17,21

500mg-1g q12h or 500mg q8h17,21

500mg-1g q24h17,21

Nitrofurantoin Contraindicated17 Contraindicated17 Contraindicated Piperacillin/ Tazobactam (TAZOCIN®)

Dose as in normal renal fun on17,21

4.5g q12h,

4.5g q12h

Teicpolanin

Give normal loading dose, then 200-400mg q48-72h17

Trimethoprim** Dose as in normal renal fun on17

GFR <15 give 50-100% of dose.17 GFR <15 give 50-100% of dose.17

17


then 125-250mg 12-24 hourly


GFR (mL/min): 40-60Dose as in normal renal function, then reduce dose after 4th day to200mg daily or 400mg every 48H

GFR (mL/min): <40Dose as in normal renal function, then reduce dose after 4th day to30% of the dose daily or 400mg every 72H

44

Appendix 11



Appendix 12: Other guideline documents to consult in association with these guidelines.

1. Guidelines for Restricted and Reserve Antimicrobials

2. Guidelines for Surgical Prophylaxis

3. South East Regional Orthopaedic Service antibiotic prophylaxis guidelines for open fractures

4. Local/National guidelines for treatment of diabetic foot infections including diabetic foot osteomyelitis

5. Post Splenectomy guidelines in adults

Individuals with an absent or dysfunctional spleen are at increased risk of severe infection, particularly with invasive pneumococcal disease. Patients must be informed of the risk, educated on how to recognise symptoms of infection and advised to seek urgent medical attention if unwell.

All patients should receive pneumococcal, Haemophilus influenzae type b and meningococcal vaccination. Vaccines should ideally be administered 2 weeks before splenectomy. If this is not possible they should be given 2 weeks after splenectomy.

All patients should receive antibiotic prophylaxis for at least 1 to 2 years. High risk patients should be offered life long antibiotic prophylaxis. Non high risk patients may choose to continue or discontinue antibiotic prophylaxis after the initial 1 to 2 year period based on a discussion of the risks and benefits of prophylaxis.

Please refer to relevant section in guideline document: Guidelines for surgical prophylaxis for full details of vaccination schedule, risk stratification of patients and antibiotic prophylaxis.

6. BNF and SPCs (Summary of Product Characteristics) and renal drug database for guidance on dosing, renal and hepatic impairment, adverse drug reactions and interactions.

Note: These guidelines are for adults only. For paediatric antimicrobial guidelines refer to local/ national paediatric guidelines.

Appendix 13: Penicillin Allergy


* It is important to document exactly what symptoms occurred before deciding if a patient is truly penicillin allergic. Check with Patient / Relatives / GP / Community Pharmacist to clarify the nature of allergic reaction.

• ManypatientsaremisdiagnosedasbeingPenicillinallergic• Anincorrectdiagnosisofpenicillinallergyleadstounnecessaryavoidanceofthisrelativelynon-toxicclassofdrugs,

exposes the patient to potentially more toxic drugs, increases health care costs and contributes to the development of antibiotic resistance.

• Patientsareoftenlabelledashavingahypersensitivityreactionwheninfactapatientmaybeexperiencingasideeffect of penicillin, such as gastrointestinal upset (e.g. nausea, diarrhoea) or headache.

• Otherconcomitantmedicinescanalsoberesponsiblefortriggeringahypersensitivityreaction.Therefore,itisimportant to consider the timeframe over which the hypersensivity reaction has developed relative to the initiation of different medications.

* Patients who have previously presented with a less severe penicillin allergy (e.g. rash) may be prescribed cephalosporins/carbapenems if the benefits outweigh the risks of cross reactivity. The potential for an allergic reaction should be monitored and resuscitation equipment available if required.

* Patients who are documented as having experienced a severe reaction (anaphylaxis) from a penicillin should not be prescribed cephalosporins, carbapenems and other betalactam containing antibiotics where acceptable alternatives available. A risk-benefit assessment may be needed in certain circumstances. Discuss individual case with senior clinician and clinical microbiology team if needed.

CONTRA-INDICATED*

CAUTION*

AmoxicillinAugmentin* (co-amoxiclav)Benzathine penicillinFlucloxacillinHeliClear*Penicillin C (benzylpenicillin)Penicillin V (phenoxymethyl)Piperacillin

Procaine penicillinTazocin* (piperacillin plus tazobactam)Timentin* (ticarcillin plus clavulanic acid)

CefalexinCefiximeCefotaximeCefazolinCeftazidimeCeftriaxone

CefuroximeImipenem plus cilastatinMeropenemAztreonam

In all patients with Penicllin allergy

May be safe to use in patients with non-type 1 penicillin hypersensitivity (NOT IgE

mediated reaction/anaphylaxis).

Common antimicrobials listed - List not exhaustive

Common antimicrobials listed - List not exhaustive

46



Contact Numbers

Microbiology Department UHW:

University Hospital Waterford switch 051-848000

Microbiology SpRs Ext. 8053

Dr. M. Hickey Ext.

Dr. M. Doyle Ext. 2621/2097

Dr. B. Carey Ext.

Dr. C. Fielding Ext.

Pharmacy Departments:

UHW Antimicrobial Pharmacist Ext. 2530/2453

WGH Antimicrobial Pharmacist Ext. 3261

SLKK/Kilcreene Antimicrobial Pharmacist Ext. 5372/5328

STGH Antimicrobial Pharmacist Ext. 7119

48

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.

11. Royal College of Obstretricians Green top guideline no 64A Bacterial Sepsis in Pregnancy. 12. HSE Adult Patient Observation Chart. 13. Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland Update of 2008

Guidance HPSC 201314 Sepsis Management. National Clinical Guideline No.6. National Clinical Effectiveness Committee, Nov.

201415 BNF 59 March – September 201516 Gilbert N, Chambers F, Eliopoulos G et al Sanford Guide to Antimicrobial Therapy 2014 44th Edition17 Ashley C, Dunleavy A. 2014. The renal drug database. Available at www.renaldrugdatabase.com18 Amikacin Product SPC accessed online 29th May 2015 on www.medicines.ie19 Ali MZ & Goetz MB: A meta analysis of the relative efficacy and toxicity of single daily dosing versus

multiple daily dosing of aminoglycosides. Clin Infect Dis 1997; 24;20 UpToDate, www.uptodate.com21 Summary of Product Characteristics (SPC) www.medicine.ie22 Guidelines for the Prevention and Control of Multi-drug resistant organisms (MDRO) excluding MRSA

in the healthcare setting. Published on behalf of the Royal College of Physicians clinical advisory group on Healthcare Associated infections in association with HSE Quality and Patient Safety

23 Guidelines for Emergency Management of Injuries. 2012. www.emitoolkit.ie



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Guidelines for the empiric use of antimicrobials in …...Document indication for therapy and intended duration in medical record. Note these guidelines are intended for empiric therapy