Information for Clinicians Microbiology Department Guideline for the Empirical Treatment of Infections in Adults ______________________________________________________________________ Appropriate prescribing of antibiotics Decision to prescribe The use of antibiotics carries significant risks to the patient and the decision to prescribe an antibiotic should always be clinically justified following a risk-benefit assessment. Do not start antibiotics in the absence of clinical evidence of bacterial infection unless the patient is gravely ill and sepsis is part of the differential diagnosis. If the clinical picture is not clear and the patient is stable, it may be possible to wait, monitor the patient clinically and review with laboratory results. If there is evidence/suspicion of sepsis, use local guidelines to initiate broad spectrum antibiotic treatment within one hour of diagnosis (or as soon as possible) in patients with life threatening infections. Delay in starting adequate antibiotic therapy in severe infection is associated with increased morbidity and mortality. Individual patient and drug-specific factors to consider in all cases include: • previous antimicrobial history • previous colonisation or infection with multi-resistant organisms • allergies and other side effects (including risk of Clostridium difficile infection) • contraindications and cautions • availability of and absorption by oral route Appropriate specimens for microscopy, culture and sensitivity should be obtained prior to commencing antibiotics wherever possible but do not delay starting treatment in patients who are severely ill. Minimising the use of broad-spectrum antibiotics The use of broad-spectrum antibiotic agents is a major factor in inducing C. difficile infection. In addition there is evidence to show an association between total antimicrobial use and use of some specific classes of antibiotics with higher MRSA prevalence. Clinicians should avoid the use of cephalosporins, quinolones, broadspectrum penicillins (including amoxicillin) and clindamycin unless there are clear clinical indications for their use. Broad-spectrum antibiotics should be restricted to the treatment of serious infections when the pathogen is not known or when other effective agents are unavailable. Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 1 of 26 Documentation The clinical indication, duration or review date, route and dose should be clearly documented in the patient’s medical notes and on the drug chart. Reasons for any deviations from empirical treatment guidelines should be recorded in the patient’s medical notes. Allergies must be recorded in the patient’s medical notes and on the front of the drug chart and anaesthetic record, along with the nature of the reaction. Review of antibiotic treatment Review the clinical diagnosis and the continuing need for antibiotics by 48 hours then daily with a clear plan of action - the “Antimicrobial Prescribing Decision”. The five Antimicrobial Prescribing Decision options are: 1. Stop antibiotics if there is no evidence of infection 2. Switch IV to Oral 3. Change antibiotics – ideally to a narrower spectrum – or broader if required 4. Continue and review again after a further 24 hours 5. Outpatient Parenteral Antibiotic Therapy (OPAT) It is essential that the review and subsequent decision is clearly documented in the medical notes. Treatment with antibiotics should not continue beyond 7 days (IV and oral) unless recommended by a local guideline or microbiologist. Department of Health Guidance recommend a Start Smart - then Focus approach for all antibiotic prescriptions Start smart is: • Do not start antibiotics in the absence of clinical evidence of bacterial infection • If there is evidence/suspicion of bacterial infection, use local guidelines to initiate prompt effective antibiotic treatment • Document on drug chart and in medical notes: clinical indication, duration or review date, route and dose • Obtain cultures first • Prescribe single dose antibiotics for surgical prophylaxis; where antibiotics have been shown to be effective Then focus is: • Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and make a clear plan of action - the “Antimicrobial Prescribing Decision” • The five Antimicrobial Prescribing Decision options are: - Stop antimicrobials - Switch IV to Oral - Change, - Continue - Outpatient Parenteral Antibiotic Therapy (OPAT). Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 2 of 26 Intravenous or oral therapy Intravenous (IV) therapy should only be used for patients with severe infections, patients who have a focus of infection requiring high doses of antibiotics, patients who are unable to take or absorb oral antibiotics, and when there are no alternative suitable oral agents. IV antibiotics should be reviewed on a daily basis and, if appropriate, the patient switched to an oral equivalent within 24 hours of meeting switch criteria. Oral switch criteria are: • • • • • • temperature < 37.5 °C for 24 hours signs and symptoms of infection are improving inflammatory markers are decreasing patient able to tolerate oral food and fluids absence of on-going or potential problem of absorption oral formulation or suitable oral alternative is available Exceptions to this include some serious infections where exceptionally high antibiotic tissue concentrations are essential (e.g. meningitis, infective endocarditis) or following microbiological advice. Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 3 of 26 Using this guideline This antibiotic policy gives initial empirical treatment only but should be used discriminately with consideration of contra-indications, interactions and previous culture results. Doses are based on normal hepatic and renal function in a 70kg man and may require adjustment. Durations are given as a guide but should be evaluated based on the condition being treated & the clinical response. Antibiotics should be reviewed and rationalised with microbiology results and clinical progress. • • • • • Vancomycin and Gentamicin - Always check levels at appropriate intervals and adjust dose / dosage interval accordingly. See “Guidelines for the dosing and monitoring of Gentamicin, Vancomycin and Teicoplanin” for further advice. Do not use Gentamicin for more than 7 days without discussion with a Microbiologist. Penicillin allergy - patients with a history of anaphylaxis, urticarial rash or a rash immediately after penicillin administration (type 1 allergy) should not receive a penicillin, cephalosporin or other beta-lactam antibiotic. Check before prescribing if you are unsure which class an antibiotic belongs to. Discuss alternative antibiotic treatment with a Microbiologist if a suitable one is not given in the policy. MRSA - If a patient has been in hospital for more than five days, has previously been known to be colonised with MRSA, or is at risk for MRSA colonisation (e.g. recent hospital admission or resident in a Nursing or Residential home) consider using Vancomycin or Teicoplanin. Extended Spectrum Beta-Lactamase (ESBL) producers, Vancomycin Resistant Enterococci (VRE) and other multi-resistant organisms - If a patient has been previously colonized or infected with a multi resistant organism or may have risk factors for colonisation (e.g. recurrent urinary tract infections, admitted from a nursing home or a long term catheter in situ) an alternative antibiotic regime may be necessary– discuss with Microbiology. Tetanus - for further information see ‘Immunisation Against Infectious Diseases The Green Book’ December 2006, Chapter 30: Tetanus. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAn dGuidance/DH_079917 Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 4 of 26 Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Sepsis (antibiotics should be initiated within 1 hour of diagnosis) Infection Antibiotic Treatment IV Option Comments Community-acquired sepsis of unknown origin, meningitis not suspected Co-amoxiclav 1.2g tds & Gentamicin 5mg/kg od +/- Metronidazole 500mg tds if anaerobic infection suspected If neutropenia or suspected neutropenia, see Neutropenic Sepsis Guideline Penicillin allergy: Teicoplanin 600mg 12 hourly for first 3 doses then 600mg od & Gentamicin 5mg/kg od +/-Metronidazole 500mg tds if anaerobic infection suspected Hospital acquired sepsis If ESBL producer or other multi-resistant organism present, or if concern regarding clinical response or renal function, discuss with Microbiology Discuss all cases with Microbiology within 24 hours Discuss with Microbiology Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly. See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin” Adult Empirical Treatment Guidelines: CNS Infections Infection Suspected Bacterial Meningitis Antibiotic Treatment IV Option Ceftriaxone 4g od Add Amoxicillin 2g 4 hourly if patient >50 years old or if immunocompromised or pregnant Discuss with Microbiology if recent travel abroad or penicillin allergy Comments Consider adjunctive dexamethasone (0.15 mg/kg 4 hourly for 2–4 days with the first dose administered 10–20 min before, or at least concomitant with, the first dose of antimicrobial therapy) in adults with suspected or proven pneumococcal meningitis Discuss all suspected cases with a Microbiologist Inform relevant Health Protection Unit (via switchboard) Send EDTA blood sample for Meningococcal and Pneumococcal PCR Treat for 14-21 days Suspected HSV encephalopathy Aciclovir 10mg/kg tds Dose reduction required if eGFR<50 Inform relevant Health Protection Unit (via switchboard) CSF should be sent for viral PCR Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 5 of 26 Adult Empirical Treatment Guidelines: Genitourinary • Previous urine culture results should guide empirical therapy • Review with urine culture results • Urine dipsticks are often positive in elderly patients and treatment may not be indicated – see UTI in the Non Catheterised Older Adult Guidelines Infection Antibiotic Treatment Total Duration Additional Comments 3 days Nitrofurantoin is contra-indicated in patients with eGFR <20ml/min and may be ineffective if eGFR 20-60ml/min Trimethoprim 200mg po bd Uncomplicated UTI in women (See UT I in the non catheterised Older Adult Guidelines If recent Trimethoprim use or known Trimethoprim resistant isolate: Co-amoxiclav 625mg po tds Penicillin allergy: Nitrofurantoin 50mg po qds Trimethoprim 200mg po bd UTI in men (See UTI in the non catheterised Older Adult Guidelines Mild UTI in pregnancy Pyelonephritis Urinary Catheter Infection (Urinary symptoms, fever, sepsis, ↑ inflammatory markers). 7 days If recent Trimethoprim use or known Trimethoprim resistant isolate: Co-amoxiclav 625mg po tds Discuss with Microbiology if there is high risk of, or previous infection/ colonisation with a VRE, ESBL producing isolate, or other multi-resistant organism Penicillin allergy: Nitrofurantoin 50mg po qds Cefalexin 500mg po bd IV treatment: Co-amoxiclav 1.2g tds & single dose of Gentamicin 5mg/kg Penicillin allergy: Ciprofloxacin 500mg po bd & single dose of Gentamicin 5mg/kg iv Amoxicillin1g tds & Gentamicin 5mg/kg od Oral treatment: Co-amoxiclav 625mg tds Penicillin allergy: Ciprofloxacin 500mg bd (7 days treatment only required if ciprofloxacin used) Oral treatment not recommended for empirical treatment 7 days 10-14 days Repeat MSU 7 days after completion of antibiotics as test of cure Discuss with Microbiology if there is high risk of, or previous infection/ colonisation with a VRE, ESBL producing isolate, or other multi-resistant organism 7 days Review oral switch with culture results and clinical progress 7 days Penicillin allergy: Gentamicin 5mg/kg once daily & single dose of Vancomycin 1g Discuss with Microbiology if there is high risk of, or previously infection/ colonisation with a VRE, ESBL producer, or other multi-resistant organism Consider catheter change once antibiotic known to be active against isolate Please ensure that symptoms are clearly indicated on the request form for CSU culture Adult Empirical Treatment Guidelines: Genitourinary Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 6 of 26 Infection Antibiotic Treatment Asymptomatic bacterial colonisation of urinary catheter No treatment required Epididymoorchitis STI suspected Ceftriaxone 500mg im single dose & Doxycycline 100mg po bd for 14 days OR If likely due to chlamydia or other nongonococcal organisms: Doxycycline 100mg po bd or Ofloxacin 200mg po bd OR If severe epididymo-orchitis or features of bacteraemia, Ceftriaxone 1g iv od & Gentamicin 5mg/kg iv od for 3-5 days until fever subsides, and then review with culture OR Ofloxacin 200mg po bd If systemically well Ciprofloxacin 500mg po bd Epididymoorchitis STI not suspected Total Duration Additional Comments Urinalysis for leukocytes & nitrites is non-specific in CSUs 14 days Refer to GUM 10 days If severe epididymo-orchitis or features suggestive of bacteraemia, Ceftriaxone 1g iv od & Gentamicin 5mg/kg iv od for 3-5 days until fever subsides, and then review with culture results Bacterial Prostatitis STI not suspected Ciprofloxacin 500mg po bd 28 days If STI suspected, refer to GUM Review with culture results Urethritis, Epididymo-orchitis, Prostatitis: If STI suspected refer to GUM for investigation and treatment (Ext 4558) Out of hours take (1) urethral swab for gonorrhoea culture (2) first void urine or urethral swab for chlamydia and gonorrhoea NAAT (3) MSU for culture, and then start antibiotics. Refer to GUM for follow up. Change of long term indwelling urethral catheter in males • Prophylactic antibiotics are recommended in patients with a history of catheter-associated urinary tract infection following catheter change, or if catheter change likely to be traumatic. • Be guided by culture results of pre-change CSU (please state indication for culture clearly on request form). If empirical cover necessary, give Gentamicin 1.5mg/kg iv or im Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly. See ”Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin” Adult Empirical Treatment Guidelines: Infective Endocarditis (IE) Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 7 of 26 Infection Antibiotic Treatment IV Option Comments Infective Endocarditis: indolent presentation Amoxicillin 2g iv 4 hourly & Gentamicin 1mg/kg (ideal body weight) iv bd Discuss all suspected cases with a Microbiologist within 24hours, particularly if critically ill It is preferable to wait for blood culture results before commencing treatment Take 3 sets of blood cultures from separate venepunctures before commencing treatment Send a clotted sample for baseline atypical endocarditis serology Infective Endocarditis: acute presentation (or indolent presentation with penicillin allergy) with no risk factors for multi-resistant bacteria Vancomycin iv dosed according to local guidelines & Gentamicin 1mg/kg (ideal body weight) iv bd. If eGFR <45 use Ciprofloxacin 750mg po bd/ 400mg iv bd 12 hourly instead of Gentamicin Infective Endocarditis: prosthetic heart valve or suspected MRSA Vancomycin dosed according to local guidelines & Gentamicin 1mg/kg ideal body weight 12 hourly & rifampicin 300-600mg 12 hourly po/iv (use lower dose of rifampicin if severe renal impairment) TARGET LEVELS in treatment of IE: • Vancomycin: Pre-dose 10-15mg/l but higher levels may be required (discuss with Microbiology) • Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Gentamicin: Pre-dose: <1mg/l Post dose 3-5mg/l Version: 1.0 Approved on: 2013 Review date: 2016 Page 8 of 26 Adult Empirical Treatment Guidelines: Respiratory Tract CURB-65 Guidelines to determine management of Community Acquired Pneumonia (CAP) Markers of Severity Confusion: new disorientation in person place or time or MTS of 8 or less Urea: raised >7mmol/L Respiratory rate raised ≥30/min Blood pressure: systolic <90mmHg and/or diastolic ≤ 60mmHg 65 years old or above 0-1 2 3 or more Low Severity Moderate Severity High Severity Infection Non-severe exacerbations of COPD Low severity CAP Based on clinical judgement and CURB-65 Moderate severity CAP High severity CAP Use iv treatment initially Antibiotic Antibiotic Treatment Oral Treatment IV Option Option Treat as low severity Community Acquired Pneumonia Total Duration Amoxicillin 1g tds Penicillin allergy or recent Amoxicillin: Clarithromycin 500mg po/iv bd 5 days Use IV only if unable to swallow or absorb orally If there is a high clinical suspicion of pneumonia caused by atypical pathogens (including legionella) add Clarithromycin 500mg bd to Amoxicillin 7-10 days Treat with Co-amoxiclav 1.2g iv tds instead of Amoxicillin if recent Amoxicillin use in the community Amoxicillin 1g tds & Clarithromycin 500mg po/iv bd Penicillin allergy: Vancomycin dosed according to local guidelines & Clarithromycin 500mg po/iv bd Co-amoxiclav 1.2g tds & Clarithromycin 500mg iv bd Penicillin allergy: Vancomycin dosed according to local guidelines & Clarithromycin 500mg iv bd (if preexisting chest disease, consider using Ciprofloxacin in place of Clarithromycin) Amoxicillin 500mg tds Penicillin allergy or recent Amoxicillin: Doxycycline 200mg on day 1 then 100mg od OR continue Clarithromycin 500mg bd if switching from IV Amoxicillin 500mg tds & Clarithromycin 500mg bd Penicillin allergy: Doxycycline 200mg day 1 and then 100mg od OR continue Clarithromycin 500mg bd if switching from IV Follow on from iv treatment: Co-amoxiclav 625mg tds & Clarithromycin 500mg bd Additional Comments 5 days Send urine for legionella antigen 7 - 10 days Follow on from iv treatment if Penicillin allergy: Doxycycline 200mg on day 1 then 100mg od Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust If MRSA pneumonia suspected add iv Vancomycin Send urine for legionella antigen and pneumococcal antigen Version: 1.0 Approved on: 2013 Review date: 2016 Page 9 of 26 Infection Aspiration pneumonia (inpatient < 48 hours) Aspiration pneumonia (inpatient >48 hours) Infective exacerbation of bronchiectasis, CF or other suppurative lung condition CAP pregnancy or breast feeding HAP (Hospital < 5 days and no previous antibiotics) Antibiotic Antibiotic Treatment Oral Treatment IV Option Option Co-amoxiclav 1.2g Amoxicillin 500mg po tds tds Penicillin allergy: Clarithromycin 500mg po/iv BD & Metronidazole po/iv tds Co-amoxiclav 1.2g Co-amoxiclav 625mg tds tds Penicillin allergy: Clarithromycin 500mg po/iv BD & Metronidazole po/iv tds Discuss with Discuss with Respiratory/ Respiratory/ Microbiology Microbiology Cefuroxime 1.5g tds & Clarithromycin 500mg po / iv bd Penicillin allergy: Discuss with Microbiology Co-amoxiclav 1.2g tds Penicillin allergy: Vancomycin iv dosed according to local guidelines & Ciprofloxacin po 500mg bd (or 400mg iv bd if oral route not appropriate) Amoxicillin 500mg tds & Clarithromycin 500mg bd Penicillin allergy: Clarithromycin 500mg bd Discuss with Microbiology if concerns Co-amoxiclav 625mg tds Total Duration Additional Comments 5-10 days 5-10 days Note that in the first 48 hours post aspiration, the patient may present with chemical pneumonitis for which antibiotics are not indicated According to clinical response If suspected lung abscess, necrotising pneumonia or patient very unwell , discuss with Microbiology Empirical therapy depends upon culture results. Two agents may be required. 5 -10 days Send urine for legionella antigen 7 - 10 days Penicillin allergy: Discuss with Microbiology Treat with Co-amoxiclav 625mg po tds instead of Amoxicillin if recent Amoxicillin use in the community Add Vancomycin iv dosed according to local guidelines if MRSA suspected Send legionella urinary antigen and discuss with Microbiology if any history suggestive of legionella If not responding to therapy, discuss with Microbiology Add Vancomycin iv dosed PiperacillinDiscuss with Microbiology 7 - 10 according to local tazobactam 4.5g days guidelines if MRSA tds suspected or patient very Penicillin allergy: unwell Vancomycin iv dosed according to Send urine for legionella local guidelines antigen & Ciprofloxacin po 500mg bd (or If not responding to therapy, 400mg iv bd if oral discuss with Microbiology route not appropriate) Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly. See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin” HAP (Hospital > 5 days or previous Co-amoxiclav) Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 10 of 26 Adult Empirical Treatment Guidelines: ENT Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Tonsillitis/ Quinsy Benzylpenicillin 1.2g qds Penicillin V 500mg qds 10 days Consider infectious mononucleosis Penicillin allergy: Clarithromycin 500mg bd Penicillin allergy: Clarithromycin 500mg po bd Ceftriaxone 2g iv od 10-14 days Add Metronidazole 500mg iv tds if abscess Penicillin allergy: Discuss with Microbiology Follow on from iv treatment: Co-amoxiclav 625mg tds Penicillin allergy: Discuss with Microbiology Co-amoxiclav 1.2g tds Co-amoxiclav 625mg tds 5-7 days Penicillin allergy: Doxycycline 200mg po on day 1 then 100mg po od Use iv only if unable to swallow or absorb po antibiotic OR Epiglottitis Acute sinusitis Acute severe otitis externa Invasive otitis externa Flucloxacillin 1g qds Doxycycline 200mg on day 1 then 100mg od Flucloxacillin 500mg qds Penicillin allergy or MRSA suspected: Vancomycin iv dosed according to local guidelines Penicillin allergy: Doxycycline 200mg on day 1 then 100mg od Piperacillintazobactam 4.5g tds & Gentamicin 5mg/kg iv od Discuss with Microbiology Add Metronidazole 500mg iv tds if quinsy According to clinical response According to clinical response Add Teicoplanin 600mg iv 12 hourly for first 3 doses then 600mg iv od if MRSA isolated or suspected Penicillin allergy: Discuss with Microbiology Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly. See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin” Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 11 of 26 Adult Empirical Treatment Guidelines: Bone and Joint Infection Antibiotic Treatment IV Option Total Duration Additional Comments *********Always try to take appropriate specimens for culture prior to antibiotic therapy********* Septic arthritis native joint Acute osteomyelitis Chronic osteomyelitis Diabetic foot with possible underlying osteomyelitis Flucloxacillin 2g iv Consider gonorrhoea qds & Gentamicin 5mg/kg iv od Please discuss with Microbiology within 1 week Penicillin allergy: Treatment usually requires 2 weeks iv then 4 Vancomycin iv weeks oral antibiotics dosed according to local guidelines & Ciprofloxacin 750mg po bd Flucloxacillin 2g iv Please discuss with Microbiology within 1 week qds & Gentamicin 5mg/kg iv od Discuss individual case with Microbiology If sepsis, Piperacillin-tazobactam 4.5g iv tds. Add Vancomycin iv dosed according to local guidelines if MRSA is suspected If MRSA isolated or suspected, discuss with Microbiology Rationalise therapy based on results of deep tissue culture results If MRO suspected, discuss with Microbiology If not septic, discuss with Microbiology Liaise with Diabetic Foot Team Penicillin allergy: Discuss with Microbiology Suspected prosthetic joint infection Vancomycin iv dosed according to local guidelines. Continue antibiotics until culture results are available, then review treatment with Microbiology Add Piperacillin-tazobactam 4.5g iv tds if previous or suspected infection with Gram negative organisms or patient septic or sinus present Penicillin allergy: Discuss with Microbiology Open fracture with See Antibiotic Guideline: Surgical Prophylaxis in Adults and without significant contamination Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly. “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin” Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 12 of 26 Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Co-amoxiclav 1.2g tds Antibiotic Treatment Oral Option Co-amoxiclav 625mg tds Penicillin allergy: Ciprofloxacin 400mg iv bd & Clindamycin 600mg iv qds Penicillin allergy: Ciprofloxacin 500-750mg bd & Clindamycin 300450mg qds Cellulitis Flucloxacillin 1g qds Flucloxacillin 500mg qds Penicillin allergy: Doxycycline 200mg po on day 1 then 100mg po od Bursitis Penicillin allergy or MRSA suspected: Vancomycin iv dosed according to local guidelines Flucloxacillin 1g qds Penicillin allergy or MRSA suspected: Vancomycin iv dosed according to local guidelines Flucloxacillin 1g qds OR consider Co-amoxiclav 1.2g tds if breastfeeding, post- operative or recent Flucloxacillin Penicillin allergy: Doxycycline 200mg po on day 1 then 100mg po od Human or animal bite Mastitis Penicillin allergy or MRSA suspected: Vancomycin iv dosed according to local guidelines Co-amoxiclav 1.2g tds Moderatesevere cellulitis in association with diabetes or post GI surgery Necrotising Fasciitis If severe consider adding Clindamycin 300-450mg po qds Penicillin allergy: Clindamycin 600mg iv qds & Ciprofloxacin 750mg po bd (or 400mg iv bd if oral route not appropriate) Meropenem 1g tds & Clindamycin 600mg iv qds & Metronidazole 500mg tds & single dose Gentamicin 5mg/kg Flucloxacillin 500mg qds Total Duration 7 days Additional Comments 5 - 7 days Only if severe consider adding Clindamycin 300-450mg po qds to Flucloxacillin / Vancomycin (substitute if on Doxycycline) Check tetanus status and discuss with Microbiology if human bite or concern regarding rabies 7 days Flucloxacillin 500mg qds OR consider Co-amoxiclav 625mg tds if breastfeeding, post operative or recent Flucloxacillin Penicillin allergy or MRSA suspected: Discuss with Microbiology 5-7days Co-amoxiclav 625mg tds 7 -10 days If MRSA is suspected add Vancomycin iv dosed according to local guidelines Liaise with Diabetic Foot Team Penicillin allergy: Discuss with Microbiology Not appropriate According to clinical response If suspected get an URGENT surgical opinion and discuss with a Microbiologist If MRSA is suspected add Vancomycin iv dosed according to local guidelines Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly. See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin” Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 13 of 26 Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Antibiotic Total Additional Comments Option Treatment Oral Duration Option Severe pre Discuss with According Discuss with Microbiology, Ceftriaxone 2g bd Microbiology septal and to clinical Ophthalmology and ENT orbital cellulitis Penicillin allergy or MRSA Penicillin allergy or response Consider urgent imaging suspected: Discuss with MRSA suspected: Microbiology Discuss with Microbiology Cellulitis Flucloxacillin 1g qds Flucloxacillin 500mg According Consider possibility of a deep surrounding to clinical +/- Metronidazole 500mg seated infection and referral to qds +/ulcer or response tds Tissue Viability Metronidazole pressure sore 400mg tds OR Co-amoxiclav 625mg tds Penicillin allergy or MRSA Penicillin allergy or suspected: Vancomycin iv MRSA suspected: dosed according to local Doxycycline 200mg guidelines +/on day 1 then 100mg Metronidazole 500mg tds od +/- Metronidazole 400mg tds Ulcer or Pressure relief and topical wound care should be adequate pressure sore with no evidence of cellulitis Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly. See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin” Adult Empirical Treatment Guidelines: Gynaecology Infection PID (low risk gonococcal) PID (high risk gonococcal) Antibiotic Treatment IV Option Ceftriaxone 2g od & Metronidazole 500mg tds & Doxycycline 100mg po bd Antibiotic Treatment Oral Option Ofloxacin 400mg bd & Metronidazole 400mg bd Ceftriaxone 2g od & Metronidazole 500mg tds & Doxycycline 100mg po bd IM ceftriaxone 500mg single dose then Doxycycline 100mg po bd & Metronidazole 400mg po bd Total Duration Additional Comments 14 days Pregnancy: Use Erythromycin instead of Doxycycline Refer to GUM 14 days Anaerobes are of greater importance in severe PID; Metronidazole may be discontinued in patients with mild or moderate PID who are unable to tolerate it. Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 14 of 26 Adult Empirical Treatment Guidelines: Intra-abdominal Infections Infection Antibiotic Treatment IV Antibiotic Option Treatment Oral Option Amoxicillin 1g tds & Co-amoxiclav 625mg Appendicitis, Metronidazole 500mg tds & tds & Metronidazole diverticulitis Gentamicin 5mg/kg od 400mg tds OR or peritonitis If eGFR <45, treat with Piperacillin-tazobactam 4.5g tds & Metronidazole 500mg iv tds Penicillin allergy: Penicillin allergy: Teicoplanin 600mg 12 hourly Ciprofloxacin 500 mg for 3 doses then 600mg od & bd & Metronidazole Metronidazole 500mg tds & 400mg tds Gentamicin 5mg/kg od OR If eGFR <45, discuss with Microbiology Amoxicillin 1g tds & Co-amoxiclav 625mg Cholecystitis Metronidazole 500mg tds & tds & Metronidazole and Gentamicin 5mg/kg od 400mg tds OR Cholangitis If eGFR <45, treat with Piperacillin-tazobactam 4.5g iv tds & Metronidazole 500mg iv tds Severe Pancreatitis with infected necrosis Penicillin allergy: Teicoplanin 600mg 12 hourly for 3 doses then 600mg od & Metronidazole 500mg tds & Gentamicin 5mg/kg od OR If eGFR <45, discuss with Microbiology Piperacillin/ tazobactam 4.5g tds& Metronidazole 500mg iv tds Total Duration Additional Comments 5 - 7 days Continue IV for 5-7 days if peritoneal contamination Review with culture results prior to switching to oral therapy 7 days Penicillin allergy: Ciprofloxacin 500 mg bd & Metronidazole 400mg tds Not appropriate 7 days Penicillin allergy: Discuss with Microbiology Add Gentamicin 5mg/ kg od if septic Note: Infected necrosis is rare in the first week. Infection is presumed when there is extraluminal gas in the pancreatic and/or peripancreatic tissues or when FNA is positive for bacteria and / or fungi on Gram stain and culture. Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly. See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin” Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 15 of 26 Adult Empirical Treatment Guidelines: Intra-abdominal Infections Infection Antibiotic Treatment IV Antibiotic Treatment Option Oral Option Piperacillin/ tazobactam Spontaneous 4.5g iv tds Be guided by culture Bacterial results Peritonitis Penicillin allergy: Discuss with Microbiology Variceal haemorrhage with cirrhosis Piperacillin/ tazobactam 4.5g iv tds Total Duration Additional Comments 5-7 days 5-7 days Penicillin allergy: Teicoplanin 600mg 12 hourly for 3 doses then 600mg od & Gentamicin 5mg/kg od OR If eGFR <45, discuss with Microbiology Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly. “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin” Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 16 of 26 References British National Formulary 65th edition. March- September 2013. Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI). Antimicrobial Stewardship: “Start Smart – Then Focus”. 2011. Scottish Intercollegiate Guidelines Network. Management of suspected bacterial urinary tract infection in adults. Clinical Guideline 88. Updated July 2012. British Society for Sexual Health and HIV. Management of epididymo-orchitis (2010) http://www.bashh.org/documents/3546.pdf British Society for Sexual Health and HIV. United Kingdom National guideline for the management of prostatitis (2008) IDSA Guidelines. Practice Guidelines for the Management of Bacterial Meningitis. Clin Infect Dis 2004; 39:1267–84 http://cid.oxfordjournals.org/content/39/9/1267.full Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2012; 67: 269–289. http://jac.oxfordjournals.org/content/67/2/269.full.pdf+html British Thoracic Society. Guidelines for the Management of Community Acquired Pneumonia in Adults. Thorax 2009, Vol 64 Supplement III http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Pneumonia/CAPGuideline-full.pdf IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. 2012 doi: 10.1093/cid/cir1043 http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html Repanos C, Mukherjee P, Alwahab Y. Role of microbiological studies in management of peritonsillar abscess J Laryngol Otol. 2009;123(8):877-9. doi: 10.1017/S0022215108004106. Epub 2008 Dec 4. . IDSA Guidelines. Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis. Clin Infect Dis 2002; 35:113–25. http://cid.oxfordjournals.org/content/35/2/113.full.pdf+html SIGN Guideline 117. April 2010. Management of sore throat and indications for tonsillectomy, A national clinical guideline. http://www.sign.ac.uk/pdf/sign117.pdf Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 17 of 26 BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology 2006; 45 (8): 1039-1041. http://rheumatology.oxfordjournals.org/content/45/8/1039.full.pdf+html British Society for Sexual Health and HIV. UK National Guideline for the Management of Pelvic Inflammatory Disease (2011). http://www.bashh.org/documents/3572.pdf IDSA Guidelines. Practice Guidelines for the Diagnosis and Management of Skin and Soft-tissue. Clin Infect Dis. 2005;41:1373-406. UK Guidelines for the Management of Acute Pancreatitis. Gut 2005;54:iii1-iii9 doi:10.1136/gut.2004.057026 http://gut.bmj.com/content/54/suppl_3/iii1.full AASLD Practice Guidelines. Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis. Hepatology 2007; 46 (3). http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guideli nes/prevention%20and%20management%20of%20gastro%20varices%20and%20hem orrhage.pdf Jalan R and Hayes PC.UK Guidelines on the management of patients with variceal haemorrhage in cirrhotic patients. Gut 2000;46:iii1-iii15 doi:10.1136/gut.46.suppl_3.iii1 http://gut.bmj.com/content/46/suppl_3/iii1.full IDSA Guideline. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010;50:133-64. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology 2010; 53:397417. http://www.easl.eu/assets/application/files/21e21971bf182e5_file.pdf Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Banks et al. Gut 2013;62:102–111. Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 18 of 26 Related documents • • • • • • • Guidelines for the dosing and monitoring of Gentamicin, Vancomycin and Teicoplanin Guidelines for UTI in Elderly Neutropenic Sepsis Guideline Antibiotic Guidelines: Paediatric and Neonatal Control of Infection Strategy Antibiotic prescribing Policy Antibiotic Guideline: Surgical Prophylaxis in Adults List of abbreviations CAP Community Acquired Pneumonia CF Cystic Fibrosis CSU Catheter sample of urine ESBL Extended Spectrum Beta-Lactamase HAP Hospital Acquired Pneumonia HSV Herpes Simplex Virus IE Infective Endocarditis MRO Multi-resistant organisms MSU Mid- stream urine NAAT Nucleic Acid Amplification Test OPAT Outpatient Parenteral Antibiotic Therapy PID Pelvic Inflammatory Disease STI Sexually Transmitted Infection VRE Vancomycin Resistant Enterococci Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Approved by: William Hubbard, Head of Medicine Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Version: 1.0 Approved on: 2013 Review date: 2016 Page 19 of 26 Appendix 1: Guidance on Penicillin Allergies Penicillin Containing Antibiotics: Amoxicillin Augmentin (Co-amoxiclav contains amoxicillin & clavulanic acid ) Flucloxacillin Penicillin G (benzylpenicillin) Penicillin V (phenoxymethyl-penicillin) Piperacillin + tazobactam (Tazocin) CONTRA-INDICATED Cephalosporins: Crossover allergy possible (up to 6.5%): Cefalexin(s) Cefotaxime(s) Cefradine(s) Avoid if history of immediate hypersensitivity to penicillin. Use with caution if non-severe allergy (e.g. minor rash only) Cefaclor(s) Ceftazidime(s) Ceftriaxone(s) Other beta-lactam antibiotics : Aztreonam(s) Ertapenem(s) Cefuroxime(s) Cefixime(s) Meropenem(s) ® Non Beta-lactam antibiotics: ® Amikacin (s) Azithromycin ® Chloramphenicol (s) Ciprofloxacin (s) Clarithromycin (s) Clindamycin (s) Colistin (s) Co-trimoxazole CONSIDERED SAFE Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0 Approved by: William Hubbard, Head of Medicine Approved on: 2013 Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016 Date of Issue: 2013 Page: 20 of 26 © Royal United Hospital Bath NHS Trust Page 20 of 26 Doxycycline Erythromycin Gentamicin (s) Levofloxacin ® Linezolid Metronidazole (s) Minocycline Nitrofurantoin Oxytetracycline Rifampicin Sodium Fusidate (s) Teicoplanin Trimethoprim (s) Tobramycin (s) Vancomycin Appendix 2: Prescribing and monitoring once daily Gentamicin in adults The standard treatment dose is 5mg/kg, The standard prophylaxis dose is 3mg/kg No single dose of Gentamicin should normally exceed 520mg Neutropenic sepsis dose is 6mg/kg, max dose at discretion of prescribing clinician Figure 1 Suggested gentamicin doses of 5mg/kg according to height and weight in MALE patients, taking into account a correction factor for obese patients Height in feet Male 6' 5 6' 4 6' 3 6' 2 6' 1 6' 0 5' 11 5' 10 5' 9 5' 8 5' 7 5' 6 5' 5 5' 4 5' 3 5' 2 5' 1 5' 0 280 280 280 280 280 280 280 280 280 280 280 280 280 280 280 280 280 280 60 320 320 320 320 320 320 320 320 320 320 320 320 320 320 280 280 280 280 65 320 320 320 320 320 320 320 320 320 320 320 320 320 320 280 280 280 280 70 360 360 360 360 360 360 360 360 360 360 360 320 320 320 320 280 280 280 75 400 400 400 400 400 400 400 400 360 360 360 320 320 320 320 320 280 280 80 400 400 400 400 400 400 400 400 360 360 360 360 320 320 320 320 320 320 85 440 440 440 440 440 400 400 400 360 360 360 360 360 320 320 320 320 320 90 440 440 440 440 440 400 400 400 400 360 360 360 360 360 360 320 320 320 95 480 440 440 440 440 400 400 400 400 400 360 360 360 360 360 360 320 320 100 480 440 440 440 440 440 400 400 400 400 400 400 360 360 360 360 360 360 105 480 480 440 440 440 440 440 400 400 400 400 400 400 360 360 360 360 360 110 480 480 480 440 440 440 440 440 440 400 400 400 400 400 400 360 360 360 115 480 480 480 480 440 440 440 440 440 440 400 400 400 400 400 400 360 360 120 480 480 480 480 480 480 440 440 440 440 440 440 400 400 400 400 400 400 125 520 520 480 480 480 480 480 440 440 440 440 440 440 400 400 400 400 400 130 520 520 520 480 480 480 480 480 480 440 440 440 440 440 440 400 400 400 135 520 520 520 520 480 480 480 480 480 480 440 440 440 440 440 440 400 400 140 520 520 520 520 520 520 480 480 480 480 480 480 440 440 440 440 440 440 145 520 520 520 520 520 520 520 480 480 480 480 480 480 440 440 440 440 440 150 520 520 520 520 520 520 520 520 520 480 480 480 480 480 480 440 440 440 155 520 520 520 520 520 520 520 520 520 520 480 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200 55 280 280 280 280 280 280 280 280 280 280 280 280 280 280 240 240 240 240 60 320 320 320 320 320 320 320 320 320 320 280 280 280 280 240 240 240 240 65 320 320 320 320 320 320 320 320 320 320 280 280 280 280 280 240 240 240 70 360 360 360 360 360 360 360 320 320 320 320 280 280 280 280 280 240 240 75 400 400 400 400 360 360 360 320 320 320 320 320 280 280 280 280 280 280 80 400 400 400 400 360 360 360 360 320 320 320 320 320 320 280 280 280 280 85 440 400 400 400 360 360 360 360 360 320 320 320 320 320 320 280 280 280 90 440 400 400 400 400 360 360 360 360 360 360 320 320 320 320 320 280 280 95 440 400 400 400 400 400 360 360 360 360 360 360 320 320 320 320 320 320 100 440 440 400 400 400 400 400 400 360 360 360 360 360 360 320 320 320 320 105 440 440 440 400 400 400 400 400 400 360 360 360 360 360 360 320 320 320 110 440 440 440 440 440 400 400 400 400 400 400 360 360 360 360 360 320 320 115 480 440 440 440 440 440 400 400 400 400 400 400 360 360 360 360 360 360 120 Actual weight in kg Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0 Approved by: William Hubbard, Head of Medicine Approved on: 2013 Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016 Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Page 21 of 26 480 480 440 440 440 440 440 440 400 400 400 400 400 400 360 360 360 360 125 480 480 480 440 440 440 440 440 440 400 400 400 400 400 400 360 360 360 130 480 480 480 480 480 440 440 440 440 440 440 400 400 400 400 400 360 360 135 520 480 480 480 480 480 440 440 440 440 440 440 400 400 400 400 400 400 140 520 520 480 480 480 480 480 480 440 440 440 440 440 440 400 400 400 400 145 520 520 520 480 480 480 480 480 480 440 440 440 440 440 440 400 400 400 150 520 520 520 520 520 480 480 480 480 480 480 440 440 440 440 440 400 400 155 520 520 520 520 520 520 480 480 480 480 480 480 440 440 440 440 440 440 160 520 520 520 520 520 520 520 520 480 480 480 480 480 480 440 440 440 440 165 Dosing interval and monitoring Gentamicin is cleared predominantly via the kidneys and the dosage interval needs to be increased in patients with impaired renal function. Renal Function Suggested eGFR 2 Dose Time interval First assay time Do I give next dose before assay results available? 24 hours Check level 24 hours post dose In patients <65 years old, with good urine output give 2nd dose without waiting for result (ml/min/1.73m ) Normal > 60 In patients >65 years old, wait for result before giving 2nd dose Impaired 30-60 Severe Impairment < 30 Dependent on levels Check level 24 hours post dose Wait for result before giving any further doses Discuss with microbiology • Take pre dose levels up to one hour before the second dose is given • Patients >65 years old, or with abnormal renal function or poor urine output: the pre dose gentamicin level must be ≤1mg/litre before any further dose is given • For patients with normal and stable renal function check pre dose level twice weekly • For patients with abnormal renal function, check the pre dose gentamicin level before each dose Renal function must be checked regularly. If renal function deteriorates, more frequent monitoring may be needed, the dosing interval may need to be increased or discontinuation of therapy may be required. Discuss alternative antibiotics with a Microbiologist. Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0 Approved by: William Hubbard, Head of Medicine Approved on: 2013 Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016 Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Page 22 of 26 Prescribing and Monitoring of Vancomycin Normal renal function: Age (years) Vancomycin Dose Dose Frequency <65 1000mg 12 hourly 65-75 750mg 12 hourly >75 500mg 12 hourly Check levels pre dose levels at 3rd or 4th dose and give dose Assay twice weekly if pre-dose levels <15mg/l and renal function stable Impaired renal function: Renal Impairment Suggested eGFR (ml/min/1.73m2) Age (years) Vancomycin Dose Dose Frequency Mild to moderate 45-60 >75 1000mg All ages 1000mg measure level at 24h and await the result before giving the next dose Moderate or Severe <45 Pre dose level should be <15mg/l. Consider dose reduction (e.g. to 750mg OD) if higher Renal function must be checked regularly. If renal function deteriorates more frequent monitoring may be needed. Aim for pre-dose levels 5-15mg/l (aim for 10-15mg/l for serious or deep seated infections) Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0 Approved by: William Hubbard, Head of Medicine Approved on: 2013 Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016 Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Page 23 of 26 Document Control Information Consultation Schedule Name and Title of Individual Dr Paul Lyons, Consultant Neurologist Dr Dominic Williamson, Consultant in Emergency Medicine Dr Philip Kaye, Consultant in Emergency Medicine Dr Chris Dyer, Consultant Geriatrician Dr Arnold Fernandes, Consultant in GU Medicine Dr Kate Horn, Consultant in GU Medicine Dr Anu Garg, Consultant Physician Dr Mark Mallet, Consultant Physician Dr John Linehan, Consultant Gastroenterologist Dr Ben Colleypriest, Consultant Gastroenterologist Dr Mark Farrant, Consultant Gastroenterologist Dr Julia Maltby, Consultant Gastroenterologist Dr Jonathan Quinlan, Consultant Gastroenterologist Dr Rob Lowe, Consultant Cardiologist Dr Jacob Easaw, Consultant Cardiologist Dr Vidan Masani, Consultant Respiratory Physician Dr Adam Malin, Consultant Respiratory Physician Dr Tony Robinson, Consultant Physician Dr Marc Atkin, Consultant Physician Dr Kim Gupta, Consultant Anaesthetist Dr Andy Georgio, Consultant Anaesthetist Mr Simon Gregg-Smith, Consultant Orthopaedic Surgeon Mr Steve Pope, Consultant Orthopaedic Surgeon Mr John Budd, Consultant Surgeon Mr Stephen Dalton, Consultant Colorectal Surgeon Mr Mike Williamson, Consultant Colorectal Surgeon Ms Catherine Ashworth, Clinical Director ENT Mr David Walker, Consultant Gynaecologist Mr Jon McFarlane, Consultant Urologist Mr Richard Antcliff, Consultant Ophthalmic Surgeon Date Consulted 12/9/13 12/9/13 12/9/13 12/9/13 2/8/13 2/8/13 12/9/13 12/9/13 12/9/13 25/9/13 25/9/13 25/9/13 25/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 12/9/13 The following people have submitted responses to the consultation process: Name and Title of Individual Date Responded Miss Nicola Lawrence, Consultant Breast Surgeon 20/9/13 Mr Richard Sutton, Consultant Breast Surgeon 18/9/13 Mr Nick Johnson, Consultant Gynaecologist 16/9/13 Mr Rick Porter, Consultant Gynaecologist 18/9/13 Mr David Walker, Consultant Gynaecologist 17/9/13 Mr Mike Williamson, Consultant Colorectal Surgeon 18/9/13 Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0 Approved by: William Hubbard, Head of Medicine Approved on: 2013 Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016 Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Page 24 of 26 Mr John Budd, Consultant Surgeon Dr Philip Kaye, Consultant in Emergency Medicine Miss Claire Taylor, Consultant in Emergency Medicine Dr Mark Mallet, Consultant Physician Dr Adam Malin, Consultant Respiratory Physician Dr Rob Lowe, Consultant Cardiologist Dr Jacob Easaw, Consultant Cardiologist Dr Vidan Masani, Consultant Respiratory Physician Dr Kate Horn, Consultant in GU Medicine Dr Arnold Fernandes, Consultant in GU Medicine Mr Neil Bradbury, Consultant Orthopaedic Surgeon Mr Steve Pope, Consultant Orthopaedic Surgeon Mr Allister Trezies, Consultant Orthopaedic Surgeon Name of Committee/s (if applicable) Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0 Approved by: William Hubbard, Head of Medicine Approved on: 2013 Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016 Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Page 25 of 26 12/9/13 18/9/13 17/9/13 13/9/13 16/9/13 12/9/13 12/9/13 12/9/13 2/8/13 2/8/13 17/9/13 18/9/13 7/10/13 Date of Committee Ratification Assurance Statement Dear Please review the following information to support the ratification of the below named document. Name of Guideline: Guideline for the Empirical Treatment of Infections Name of author: Wendy Fletcher and Teh Li Chin Job Title: Antimicrobial Pharmacist and Consultant Microbiologist I, the above named author, confirm that: • The Guideline presented for ratification describes best practise known to me at the time of the development of the guideline. • I will bring to the attention of my clinical director or line manger any information which may affect the validity of this Guideline as soon as this becomes known to me; • I have undertaken appropriate consultation on this Guideline and have considered all responses. • I acknowledge that the policy will be kept under review, and that I may be asked to refine the guideline. If no interim changes are required it will then be formally reviewed on its documented review date. Signature of Author: Name of Person Ratifying this Guideline: William Hubbard Job Title: Head of Medicine Signature: Date: 21/11/2013 Date: 21/11/2013 To the person approving this Guideline: Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator, John Apley Building. The whole guideline must be sent electronically to: ruh-tr.policies@nhs.net Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0 Approved by: William Hubbard, Head of Medicine Approved on: 2013 Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016 Date of Issue: 2013 © Royal United Hospital Bath NHS Trust Page 26 of 26