Title Antimicrobial Guidelines for Hospitals

Document Type Guideline

Issue no Clinical Governance Support Team Use

Issue date Jan 2014

Review date Jan 2016

Distribution All prescribers, charge nurses, clinical pharmacists

Prepared by Anne Duguid

Developed by NHS Borders Antimicrobial Management Team

Equality & Diversity

Impact Assessed

Approved By NHS Borders Antimicrobial Management Team

Document Approved Date

Addition/Amendments App iv – Surgical Prophylaxis Guidelines – 30.4.14.

Apr 14

File Location: Clin_Pharm_Antimicrobial_Guidelines

 Antimicrobial Guidelines for Hospitals

January 2014

Produced by:
NHS Borders Antimicrobial Management Team

Review date January 2016

You can access the most recent version of the Guidelines on the NHS Borders Intranet
Antimicrobials microsite.

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CONTENTS PAGE

1 INTRODUCTION ……………………………………………………………. 5
1.1 Penicillin Allergy ……………………………………………………. 5
1.2 Prudent Antimicrobial Prescribing ………………………….. 6
1.3 Antimicrobial Categories for Prescribers………………………. 7
2 SEPSIS AND BLOOD STREAM INFECTIONS ………..………………... 8
2.1 Sepsis and Sepsis 6……………….……..…………………………. 8
2.2 Sepsis of Unknown Source……………………………………..….. 10
2.3 Sepsis in Neutropenic Patients (see Appendix viii) 10
2.4 Central Catheter Related Blood Stream Infection…………….. 10
2.5 Yeast / Candida Blood Stream Infection Secondary to Long
or Central Intravascular Lines ..………………………………….. 11
2.6 Blood Stream Infection due to Staphylococcus aureus…..… 11
3 BONE AND JOINT INFECTIONS …………………………………………. 12
3.1 Septic Arthritis / Osteomyelitis ………..………………………… 12
3.2 Prosthetic Joint Infections ……………..………………………… 12
4 CENTRAL NERVOUS SYSTEM INFECTIONS …………………………. 13
4.1 Bacterial Meningitis (“Notifiable” Disease) …………………… 13
4.2 Viral Meningitis …….………………………………………………. 14
4.3 Brain Abscess …………..………………………………………….. 14
4.4 Herpes Simplex Encephalitis ………………….………………… 14
5 CARDIOVASCULAR SYSTEM INFECTIONS …………………………… 15
5.1 Infective Endocarditis ……………..……………………………… 15
6 EAR, NOSE & THROAT INFECTIONS …………………………………… 16
6.1 Dental Abscess ….…………………………………………………. 16
6.2 Otitis Externa ……….………………………………………………. 16
6.3 Otitis Media or Sinusitis ……..…………………………………… 16
6.4 Tonsillitis / Quinsy …………………….…………………………… 16
7 GASTROINTESTINAL TRACT INFECTIONS …………………………… 17
7.1 Intra-Abdominal Sepsis including Bacterial Peritonitis ….…. 17
7.2 Hepatobiliary Sepsis ……..……………………………………….. 17
7.3 Antibiotic Associated Diarrhoea …..……………………………. 17
7.4 Gastroenteritis / Food Poisoning (“Notifiable” Disease) …… 19
7.5 Oral Candidiasis …………….……………………………….…….. 19
7.6 Systemic Candidiasis …….……………………………………….. 19
7.7 Helicobacter Eradication ……….………………………………… 19
7.8 Spontaneous Bacterial Peritonitis………………………………. 20
8 URO-GENITAL SYSTEM INFECTIONS ………………………………….. 21
8.1 Pelvic Inflammatory Disease (PID) …….……………………….. 21
8.2 Gonorrhoea and/or contact with Gonorrhoea ….…………….. 21
8.3 Chlamydia …………….…………………………………………….. 21
8.4 Epididymo-orchitis ….…………………………………………….. 22
8.5 Genital Herpes …………….……………………………………….. 22
8.6 Vaginal Candidiasis …………….…………………………………. 22
8.7 Penile Candidiasis ……………………….………………………… 22
9 URINARY TRACT INFECTIONS ………………………………………….. 23
9.1 Simple Urinary Tract Infections..………………………………… 23
9.2 Catheter specimen …………..…………………………………….. 23
9.3 Urinary Tract Infections in Pregnancy ……….………………… 24
9.4 Complicated Urinary Tract Infections ………………….………. 24
9.5 Prostatitis ……….…………………………………………………… 25

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CONTENTS PAGE

10 RESPIRATORY TRACT INFECTIONS…………………………………….. 26

10.1 Acute Exacerbations of Chronic Obstructive Pulmonary…. 26
Disease
10.2 Community Acquired Pneumonia……………………………… 27
10.2.1 Legionella………………………………………………………..…. 28
10.2.2 Pneumonia post influenza ……………………………………… 28
10.3 Hospital Acquired Pneumonia…………………….……………. 28
10.4 Aspiration Pneumonia…………………………………………… 28
10.5 Ventilator Acquired pneumonia………………………………… 28
10.6 Tuberculosis ………………………………………………………. 28
11 SKIN AND SOFT TISSUE INFECTIONS…………………………………. 29
11.1 Cellulitis (not perineum)…………………………………………… 29
11.2 Diabetic Foot………………………………………………………… 29
11.3 Necrotising Fasciitis / Streptococcal Toxic Shock Syndrome 30
11.4 Surgical Wound Infection ……………………………………..….. 30
11.5 Traumatic Wounds / Lacerations………………………………… 30
11.6 MRSA Skin and Soft Tissue Infections…………………………. 31
11.7 Multiple injuries and/or compound fractures of long bones 31
11.8 Bites……………………………………………………………….….. 32
11.9 Herpes…………………………………………………………….….. 32
11.10 Leg Ulcers / Pressure Sores / PEG sites…………….….….….. 32

APPENDIX i ………………………………………………………………………… 33
MONITORING ANTIMICROBIAL DOSAGE
Gentamicin ………………………………………………………………………... 33
Vancomycin ………………………………………………………………………. 38
APPENDIX ii………………………………………………………………………… 43
PREGNANCY AND ANTIMICROBIALS
APPENDIX iii……………………………………………………………………….. 44
ANTICOAGULANTS AND ANTIMICROBIALS
APPENDIX iv……………………………………………………………………….. 45
SURGICAL PROPHYLAXIS GUIDELINES
APPENDIX v………………………………………………………………………… 48
GUIDELINES FOR THE PROTECTION OF THE ASPLENIC
PATIENT
APPENDIX vi……………………………………………………………………….. 49
PROPHYLAXIS OF INFECTIVE ENDOCARDITIS
APPENDIX vii………………………………………………………………………. 50
GENERAL GUIDANCE FOR IV TO ORAL SWITCH
Appendix viii 52
PROTOCOL FOR MANAGEMENT OF PATIENTS WITH………………….…
NEUTROPENIC SEPSIS AT BORDERS GENERAL HOSPITAL
APPENDIX ix…………………………………………………………………..…… 54
RENAL IMPAIRMENT AND ANTIBIOTICS

4
1 INTRODUCTION

This guidance is intended to assist medical staff to make a rational choice of an

antimicrobial before drug sensitivities are known.

It takes into account national and local guidelines and local sensitivities. Reference should
also be made to guidelines for specific areas such as critical care.

Unless otherwise stated, the guidance refers to the treatment of adult patients.

Doses quoted are for patients with normal renal function.

Please feel free to discuss infection problems with the Consultant Microbiologist.

Telephone Numbers:
Consultant Microbiologist ……………………………………………… Extension 26231
Microbiology Laboratory ………………………………………………. Extension 26250
Microbiology Secretary ………………………………………………… Extension 26262
Advice is also available from Pharmacy:
Antimicrobial pharmacist Extension 26782
Dispensary ……………………………………………………………… Extension 26609/10

Antimicrobial therapy should be reviewed daily, in the light of:

• Culture results
• Allergy or adverse reaction
• None-response
• Microbiology consultation

1.1 Penicillin Allergy

The BNF has clear guidance on penicillin hypersensitivity. In this guideline, alternatives to
penicillins are given as appropriate to the clinical scenario. Cephalosporins or other beta-
lactam antibiotics (including piperacillin / tazobactam and meropenem) should NOT be given
to patients with a history of anaphylaxis, angio-oedema, bronchospasm, urticaria or rash
occurring immediately after penicillin administration. Please speak to a Consultant
Microbiologist in such cases.

NHS Borders Infection Control Manual contains policies related to the management of patient
with infection and infectious disease and the control and prevention of cross infection (found in
all wards / departments or on the NHS Borders intranet).

Other useful websites:

British Society for Antimicrobial Chemotherapy: Treatment of Hospital

Infections……………………………………………………….. http://www.bsac.org.uk/pyxis/
British National Formulary …………………………………… http://www.bnf.org
Health Protection Scotland ………………………………….. http://www.hps.scot.nhs.uk

5
1.2 Prudent Antimicrobial Prescribing

When choosing Antimicrobials consider:

1. Choice
• The likely organisms causing the infection
• Allergies and contra-indications
• Previous antimicrobial therapy
• Antimicrobial likely to achieve adequate concentrations at site of infection?
• Change according to culture and sensitivities
• Site of infection
• Severity.
• Age, weight, renal and hepatic function of the patient
• Consider oral route if appropriate for the patient
• Reassess IV route within 48 hours (see Appendix vii, General Guidance on IV to Oral
Switch Guidelines). Choose oral antibiotic according to guideline or according to
sensitivities.

2. Duration
• According to guidelines. Otherwise keep to 5 days and then review
• Always indicate a stop date or course length in the drug kardex and patient case notes
• Remember antimicrobials must be given regularly, e.g. every 6 hours or 8 hours

When writing prescriptions for Antimicrobials

Please refer to the British National Formulary for general guidance on prescribing and
prescription writing.

British National Formulary ………………………………………. http://www.bnf.org

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1.3 ANTIMICROBIAL CATEGORIES FOR PRESCRIBERS

To assist in the management of antimicrobial prescribing, and minimise the emergence

of resistance amongst bacteria, the antimicrobials stocked in Pharmacy are grouped
into three categories.

Group I

Antimicrobial agents, which can be prescribed by all doctors when appropriate:

Amoxicillin Flucloxacillin
Benzylpencillin Fluconazole oral
Cefalexin Gentamicin
Cefotaxime (for CNS infections) * Metronidazole
Chloramphenical (eye preparations) Nystatin suspension
Clarithromycin IV Phenoxymethylpenicillin
Clarithromycin oral Rifampicin (meningococcal prophylaxis)
Doxycycline oral Trimethoprim

Group II
Antimicrobial agents that can only be prescribed for specific conditions, or infections as per
antimicrobial guideline, or when indicated by culture and sensitivity results.

Azithromycin (STI only) Fluconazole IV

Cefixime (STI only) Mupirocin nasal ointment
Ceftazidime – Naseptin
Ceftriaxone (STI only) Ofloxacin (STI only)
Chlorampenicol Rifampicin (TB & Meningococcal Prophylaxis)
Ciprofloxacin Sodium Fusidate oral
Clindamycin *piperacillin/tazobactam
*Co-amoxiclav Teicoplanin
Co-trimoxazole Vancomycin

Group III**
Antimicrobials that can only be prescribed on the advice of a Consultant Microbiologist.

Amphotericin IV * Meropenem
Caspofungin Rifampicin
Ceftriaxone (except for STI) Sodium Fusidate IV
Flucytosine Voriconazole
5FC (Flucytosine)

* Do not prescribe metronidazole with co-amoxiclav (amoxicillin / clavulanic acid), piperacillin/

tazobactam or meropenem

** In extreme circumstances, the critically ill patient may require antimicrobials out of Group III
prior to discussion with the Consultant Microbiologist. The Consultant Microbiologist should
be contacted as soon as possible in such circumstances.

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2.0 SEPSIS AND BLOOD STREAM INFECTIONS

2.1 SEPSIS AND SEPSIS 6

Sepsis is important: it kills more people than acute myocardial infarction!

Prompt management of sepsis saves lives.
The goal of the Sepsis 6 is to reduce mortality by 25%

What is the Sepsis 6?

A bundle of interventions to be achieved within 1 hour (see below).

What triggers the Sepsis 6?

Any patient with a SIRS score of 2 or more (2 or more yellow boxes) and a suspicion of
infection driving this inflammatory response.

What do you do?

All of the actions below. To make it easier, there is a sticker to document all of it in the notes.
Use this as it helps us to audit the patients with sepsis.

SEPSIS 6

1. Give high flow oxygen

2. Take blood cultures (ideally before antibiotics start)
3. Give iv antibiotics
4. Start iv fluid resuscitation
5. Check lactate (needs a yellow tube) and FBC (use
sepsis order set)
6. Monitor hourly urine output.

and refer patient to critical care outreach

Easy. 3 things to check (lactate, blood cultures and urine output) and 3 things to do (give
oxygen, fluids and antibiotics). The blood tests are part of the ‘Sepsis 6’ order set on Trak.

IMPORTANT: the patient has to actually receive the antibiotics to get any benefit from them. If
this means administering them yourself then that is a good use of anybody’s time!

Treatment of Sepsis
There are three key features of the management of the patient with sepsis:

1. Recognition: early recognition is crucial to improvement of mortality from this important

condition. In the BGH the SIRS chart will capture these patients early, and with a
confirmed or suspected source of infection the diagnosis is made.

2. Prompt diagnosis and treatment: Sepsis 6: complete the bundle within 1 hour.
Administration of appropriate IV antibiotics to the septic patient is essential: for
every hour you delay the mortality can increase by 7%.

8
 3. Organ support: if required the patient may need organ support in the ITU. Referral of
all patients with sepsis to Critical Care Outreach will make this process easier.

Your goal is to break the chain of progression from infection to sepsis to septic shock
to multiple organ failure to death. With the Sepsis 6 bundle we can do that – and
reduce the chances of patients dying.

Definition Mortality
Infection Organisms at a normally sterile site with some
inflammation.

SIRS Systemic Inflammatory Response Syndrome

Host inflammatory response
May or may not be caused by infection
2 or more of:
▫ Temperature >38oC or < 36oC
▫ Heart Rate >90 beats/min
▫ Respiratory rate >20
▫ White Cell3
Count >12,000 cell/mm3 or < 4,000
cell/mm

Sepsis Suspected or confirmed infection plus SIRS 10-15%

Severe Sepsis Sepsis with dysfunction of one or more organs 20-30%
▫ Elevated Lactate
▫ Altered mental state
▫ Oliguria
▫ Hypotension
Septic Shock Sepsis induced hypotension (<80mmmHg or 30% less 40-60%
than normal) despite adequate fluid resuscitation

Multiple Organ Failure of more than two organ systems requiring acute 60-80%
Failure support as a result of sepsis.

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2.2 SEPSIS OF UNKNOWN SOURCE

If the source of infection is known, antimicrobial therapy can be based on the most suitable
empirical therapy for the infection, pending results of culture and susceptibility tests.

If source is unknown, take appropriate samples of specific body fluids, e.g. urine, sputum to
determine the source of infection.

Sepsis of unknown source

Initial Treatment

Co-amoxiclav 1.2g IV 8 hourly

plus
Gentamicin extended interval dosing See Appendix i, Monitoring Antimicrobial Dosage

If MRSA suspected add Vancomycin IV (see Appendix i, Monitoring Antimicrobial Dosage)

If intra-abdominal source suspected see Section 7.1.

Penicillin allergy
Vancomycin (see Appendix I, Monitoring Antimicrobial Dosage)
Plus
Ciprofloxacin 400mg IV 12 hourly ( IV for first dose then review if appropriate to switch
patient to oral)
Plus
Metronidazole 500mg IV 8 hourly

Change according to results of sensitivities. Switch to oral as soon as appropriate.

2.3 Sepsis in Neutropenic Patients (see Appendix viii)

Take initial sets of blood culture samples, up to 2 sets advised (one from peripheral site and
one from line, if in-situ). Patients receiving nephrotoxic chemotherapy, e.g carboplatin or
cisplatin should not receive Gentamicin: contact Consultant Microbiologist or Haematologist
for advice.

Initial Treatment

Piperacillin / tazobactam 4.5g IV 6 hourly

plus
Gentamicin extended interval dosing. See Appendix i, Monitoring Antimicrobial Dosage.

Penicillin Allergy See Appendix viii

Modify treatment on result of culture and discuss with Microbiologist and/or

Haematologist if no improvement.

2.4 Central Catheter Related Blood Stream Infection

The priority is prevention of infection from these lines. Adhere rigidly to the care bundles for
these lines. Review the need for the line daily and if not required remove it. The rate of

10
infection from these lines has been significantly reduced by following these rules and very
careful insertion in the first place.
If infection from a central line is suspected (Catheter Related Blood Stream Infection) the
default position should be to remove the line. For tunnelled lines (Hickman lines) this is
difficult, so discuss with a Consultant Haematologist.

The tip of the removed central line should be sent for culture along with peripheral blood
cultures. For removal of central lines, advice and guidelines are available from ITU.

If antibiotics are required

As most line infections are due to coagulase-negative staphylococci, initial therapy should be
directed against these organisms.

Vancomycin seeAppendix i Monitoring Antimicrobial Dosage.

or Teicoplanin 400mg IV 12 hourly for 3 doses then 400mg 24 hourly

Review Daily (Check dose with Microbiologist as in some cases 10mg/kg required).

If sensitivities show methicillin sensitive Staphylococcus aureus change to

Flucloxacillin 1g IV 6 hourly for 14 days total. CSM advice (hepatic disorders) see BNF.

Antibiotics should be reviewed after 48 hours when cultures results are available and if
necessary de-escalated. They may no longer be required after removal of the line, or could be
changed to match the sensitivities of any organisms detected. Clinical judgement and
discussion with Consultant microbiologist is required.

2.5 Yeast / Candida Blood Stream Infection

Secondary to Long or Central Intravascular Lines

Always discuss with Consultant Microbiologist. Early removal or change of line(s) is

fundamental to management.

Initial Treatment

Fluconazole 400mg IV stat, then 200mg to 400mg IV / oral once daily.

2.6 Blood Stream Infection due to Staphylococcus aureus.

Staphylococcus aureus sepsis is a serious condition and can be associated with deep seated
infections and severe sequelae. Any patient with blood cultures positive for Staphylococcus
aurues must be treated with a minimum of 2 weeks IV antibiotic therapy. If investigations show
a deep seated source, longer treatment will be required, please discuss with microbiology.

If Staphylococcus aureus is flucloxacillin sensitive, treat with IV flucloxacillin 1-2 grams 6

hourly.

If flucloxacillin resistant, use vancomycin (See Appendix i Monitoring Antimicrobial Dosage)

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3 BONE AND JOINT INFECTIONS

3.1 Septic Arthritis / Osteomyelitis (Native joint, not diabetic ulcer associated)

Blood cultures, joint aspirates and other appropriate samples from potential source of infection
MUST be taken prior to therapy.

Discuss with Consultant Microbiologist if risk of Methicillin resistant Staphylococcus aureus or

Staphylococcus epidermidis or if gonococcal septic arthritis is suspected.

All therapy should be modified with culture results.

Initial Treatment
First 2 weeks Flucloxacillin 1g to 2g IV 6 hourly
CSM advice (hepatic disorders) see BNF

Third week Flucloxacillin 500mg to 1g IV or oral 6 hourly

onward, if
infection
confirmed
If infection not confirmed discuss with microbiology

Penicillin Allergy
First two Weeks Vancomycin, (see Appendix i, monitoring antimicrobial dosage)

Third week Doxycycline 200mg daily

onward, if
infection
confirmed
If infection not confirmed discuss with microbiology

If risk factors for gram negative infection (for example UTI, prostate symptoms, recent intra-
abdominal surgery), add Gentamicin as single daily dosing. See Appendix i, Monitoring
Antimicrobial Dosage

Effectiveness of therapy can be monitored using CRP estimation once or twice each week.

Duration Treatment: Septic arthritis: 4 to 6 weeks

Osteomyelitis: up to 6 months

3.2 Prosthetic Joint Infections

Establish the microbiology of the infection. If occurring within 6 months of surgery, the
organism is commonly Staphylococcus aureus. If the infection is late onset, it is usually
coagulase-negative staphylococci or Gram-negative bacilli.

Discuss all cases with Consultant Microbiologist as a variety of antibiotic combinations

may be appropriate.

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4 CENTRAL NERVOUS SYSTEM INFECTIONS

4.1 Bacterial Meningitis (“Notifiable” Disease)

On admission (adults)
Cefotaxime 2g IV 6-8 hourly
change to
Benzylpenicillin 2.4g IV 4 hourly if culture shows meningococcal disease or sensitivities
indicate

In all patients over 55 years or immunocompromised, and in all other cases where Listeria is
suspected, add amoxicillin 2g IV every 4 hours.

Penicillin Allergy
If history of anaphylaxis or bronchospasm with Penicillin, discuss with Consultant
Microbiologist
Chloramphenicol 25mg/kg IV 6 hourly
Duration of Treatment
Meningitis caused by meningococci Treatment for 5-10 days may suffice
Meningitis caused by pneumococci Treatment for 10-14 days

Seek advice from Consultant Microbiologist if isolates unusual, in the

immunocompromised, post neurosurgery or when the aetiology is in doubt.
Chemoprophylaxis of Meningococcal Disease
First choice
Ciprofloxacin for most age groups and in pregnancy (rifampicin if <1 month)
Given on advice of Public Health Doctor, contact through switchboard.

Doses (all oral)

Adults and Children over 12 years Ciprofloxacin 500mg as a single dose
Children aged 5 – 12 years Ciprofloxacin 250mg as a single dose
Children 1 month to 4 years Ciprofloxacin 125mg as a single dose
Children under 1 month Rifampicin 5mg/kg every 12 hours for 2 days

The administration of ciprofloxacin may be followed by anaphylactic reactions. Healthcare

staff should give out information sheets that include the risk of side effects and be prepared
to deal with allergic reactions. It can also interact with other drugs but a single dose is
unlikely to have a significant effect. It has an unpredictable effect on epilepsy.

Further information including alternative regimens and information sheets can be found at
www.hpa.org.uk in the section on meningococcal disease.

13
4.2 Viral Meningitis
Antimicrobials not indicated unless Herpes viruses suspected.

Take extra CSF sample for Enterovirus or Herpes Simplex virus (HSV) PCR, as appropriate,
as well as throat swab in viral transport medium.

4.3 Brain Abscess

Usually causative agents are: anaerobes, Streptococcus species or Enterobacteriacae
Cefotaxime 2g IV 6-8 hourly
plus
Metronidazole 500mg IV 8 hourly

4.4 Herpes Simplex Encephalitis

Take CSF sample for HSV PCR

Aciclovir 10mg/kg IV 8 hourly for 10 days

14
5 CARDIOVASCULAR SYSTEM INFECTIONS

5.1 Infective Endocarditis

Discussion of all cases of endocarditis (including culture negative) with a Consultant

Microbiologist and Cardiologist is strongly advised.

Send three sets of blood cultures, from separate sites, over a 24 hour period if possible. In
the acutely ill, two sets should be taken within 1 hour before starting empirical therapy.

Initial Empirical Treatment

Native Valve Endocarditis (NVE) - Indolent presentation

Amoxicillin 2g IV 4 hourly
alone or plus
Gentamicin see divided dosing protocol appendix i Monitoring Antimicrobial Dosage

If genuine penicillin allergy, use regimen for severe sepsis, below.

NVE severe sepsis

In severe sepsis, Staphylococci spp. need to be covered. Patients at increased risk of
staphylococcal endocarditis include iv drug abusers and patients with intravascular devices.

Vancomycin – for dosing regimen see Appendix i Monitoring Antimicrobial Dosage

plus
if eGFR>30 ml/min Gentamicin. See divided dosing protocol Appendix i Monitoring
Antimicrobial Dosage
if eGFR <30 ml/min use ciprofloxacin as alternative

If patients have risk factors for multiresistant Enterobacteriaceae or Pseudomonas, eg.

evidence of previous colonisation, use meropenem 2g 8 hourly in place of gentamicin.

Prosthetic valve endocarditis (PVE)

Vancomycin – for dosing regimen see Appendix i Monitoring Antimicrobial Dosage
plus
Rifampicin oral 300mg to 600mg 12 hourly
plus
if eGFR>30 ml/min Gentamicin. See divided dosing protocol Appendix i Monitoring
Antimicrobial Dosage
If eGFR <30 ml/min use ciprofloxacin as alternative

Once causative organisms are known antibiotics should be tailored to the organisms isolated
following discussion with the Consultant Microbiologist.

Treatment follows the British Society for Antimicrobial Chemotherapy (BSAC) Endocarditis
Working Party recommendations.

Reference:
Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the
Working Party of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial
Chemotherapy 2012, 67, 269-289 http://jac.oxfordjournals.org/content/67/2/269.full.
15
6 EAR, NOSE, MOUTH AND THROAT INFECTIONS

6.1 Dental Abscess

Penicillin V 500 mg oral 6 hourly

(some advocate Amoxicillin 250 mg oral 8 hourly but BEWARE side effects diarrhoea,
candidiasis)

Penicillin allergy
Metronidazole 400 mg oral 8 hourly

6.2 Otitis Externa

Refer to Borders Joint Formulary “Infections” section.

6.3 Otitis Media or Sinusitis

Refer to Borders Joint Formulary “Infections” section.

6.4 Tonsillitis / Quinsy

Refer to Borders Joint Formulary “Infections” section

16
7 Gastrointestinal Tract Infections

7.1 Intra-Abdominal Sepsis including Bacterial Peritonitis

Initial Treatment

Amoxicillin 1g IV 8 hourly
plus
Metronidazole 500mg IV 8 hourly
plus
Gentamicin (Extended Interval Dosing. See Appendix i Monitoring Antimicrobial Dosage)

Penicillin or Cephalosporin allergy

If B-lactam allergy, consider vancomycin plus ciprofloxacin plus metronidazole
and discuss with Microbiologist

7.2 Hepatobiliary Sepsis

Amoxicillin 1g IV 8 hourly
plus
Metronidazole 500mg IV 8 hourly
plus
Gentamicin (Extended Interval Dosing. See Appendix i Monitoring Antimicrobial Dosage

Penicillin or Cephalosporin allergy

If B-lactam allergy, consider vancomycin plus ciprofloxacin plus metronidazole, and discuss
with Microbiologist.

7.3 Antibiotic Associated Diarrhoea

Only 40% of cases are associated with Clostridium difficile toxin production. All are due to
disruption of the normal bowel flora. There is no need to send repeat specimens from patients
with previous positive results unless there is a recurrence after a full course of treatment.

If possible, STOP all antimicrobials. Discuss continuation of therapy with Consultant

Microbiologist. Diarrhoea will begin to settle in 2 to 3 days in the majority of patients.
Consider oral rehydration therapy. Consider treating according to protocol below if
C.difficile toxin found in stool and if diarrhoea is bloody, persists, is severe or patient
has abdominal distension and fever.

17
 NHS Borders Treatment of C.difficile-associated disease (CDAD): first and second
episodes

• Treatment of CDAD should be initiated based on assessment of symptoms and severity of

disease while taking into account individual risk factors of the patient.
• Consider treatment if C.difficile toxin found in stool and if diarrhoea is bloody, persists, is
severe or patient has abdominal distension and fever
• Antibiotic treatment is not required if patient has C.difficile toxin and non or resolving diarrhoea

• Ensure infection prevention and control measures are in

place as soon as symptoms occur (do not wait for lab result
to confirm diagnosis before putting control measures in
place)
• Stop any (non-C.difficile) antimicrobial treatment in patients
with CDAD if possible. Discuss continuation of any therapy
with microbiologist
• Stop gastric acid suppressive therapy if possible e.g. PPIs,
H2 antagonists.

Severity markers:
• Temperature >38.5°C
• Patient has major risk factors (eg. immunosupression)
• Hypotension (systolic bp <90mm/Hg)
• Suspicion of pseudomembranous colitis, toxic megacolon, ileus
• Colonic dilatation in CT scan >6 cm (CT scan not routinely recommended)
• White blood cell count > 15x109cells/l
• Creatinine>1.5 x baseline
• Albumin <25 g/l

Patient has no severity Patient has one or more

markers: severity markers:
Treat with oral metronidazole Treat with oral vancomycin
400mg 8 hourly for 10-14 days 125mg 6 hourly for 10-14
Rehydrate patient days
Rehydrate patient

Daily assessment of patient with severe disease:

Daily assessment of patient with mild to Observe bowel movement, symptoms
moderate disease: (WBC&hypotension) and fluid balance.
Observe bowel movement, symptoms Surgery, gastroenterology and microbiology
(WBC&hypotension) and fluid balance consultations.
CT scanning: consider pseudomembranous colitis, toxic
If condition doesn’t improve after 5 days’ megacolon, ileus or perforation.
treatment with oral metronidazole, patient
should be switched to treatment with oral Patients with severe CDAD with hypotension or ileus
vancomycin (125mg 6 hourly for 10-14 days) should receive IV metronidazole 500mg 8 hourly in
addition to oral vancomycin for 10-14 days or as
recommended by Consultant Microbiologist.

If diarrhoea continues, or is a third episode, or in severe disease, discuss further management with
Consultant Microbiologist. Probiotics may be initiated by specialists in patients experiencing a third or
subsequent episode.

18
7.4 Gastroenteritis / Food Poisoning (“Notifiable” Disease)

In general, antimicrobial therapy should be avoided, as most bacterial infections are

self-limiting. Generally antibiotics only reduce diarrhoea by 1-2 days, can cause resistance
and are contraindicated in E. coli 0157 infection where they may enhance toxin release and
increase the risk of haemolytic uraemic syndrome.

If patient is immunocompromised, or has signs/symptoms suggestive of deep seated or

invasive infection, please discuss treatment options with a Microbiologist.

Stool and, where appropriate, blood cultures should be taken and clearly labelled with relevant
history, including travel history.

7.5 Oral Candidiasis

First choice
Fluconazole 50mg to 100mg oral 24 hourly for 7 to 14 days

Second choice
Nystatin suspension 100 000 units per ml, 1ml 6 hourly after food usually for 7 days
(continue for 48 hours after lesions have resolved)

7.6 Systemic Candidiasis

Discuss with Consultant Microbiologist

Fluconazole 400mg oral initially then 200 - 400mg daily
(IV only if oral route not possible)

7.7 Helicobacter Eradication

First line treatment

Omeprazole 20mg 12 hourly for 7 days
Clarithromycin 500mg oral 12 hourly for 7 days
Amoxicillin 1g oral 12 hourly for 7 days

or

Omeprazole 20mg 12 hourly for 7 days

Clarithromycin 250mg oral 12 hourly for 7 days
Metronidazole 400mg oral 12 hourly for 7 days

Second line treatment

See BNF for alternative regimes. Refer patient to specialist if eradication has failed
with ONE of the above regimens.

Any antibiotic used recently should be avoided in the eradication regime.

19
7.8 Spontaneous Bacterial Peritonitis

First line treatment

Co-amoxiclav 1.2g IV 8 hourly

Second line treatment

Cefotaxime 2g IV 8 hourly

Or, in immediate (type 1) beta-lactam sensitivity,

Vancomycin IV (see appendix i: monitoring antimicrobial dosage)
plus
Ciprofloxacin 500mg oral 12 hourly (IV if enteral route unavailable). Consult Microbiologist if
patient has been receiving a quinolone as SBP prophylaxis.

Prophylaxis
Norfloxacin 400mg oral daily

20
8 URO-GENITAL SYSTEM INFECTIONS

It is essential that Sexually Transmitted Infections especially Chlamydia, Gonorrhoea, and

Syphillis are reported to GUM Clinic for follow-up and contact tracing. Also see
www.borderssexualhealth.org

Failure to refer carries a high risk of re-infection.

GUM Health Advisors should be contacted on the following numbers:

GU Clinic, Galashiels Health Centre
01896 663700

8.1 Pelvic Inflammatory Disease (PID)

Treatment follows NHS Borders STI Management Protocol.

Antimicrobial treatment should be commenced as soon as diagnosis is suspected.
Women with suspected PID should be screened for Gonorrhoea and Chlamydia.

Out-Patient or non-severe
Ofloxacin 400mg oral 12 hourly for 14 days
CSM advice (tendon damage) see BNF
plus
Metronidazole 400mg oral 12 hourly for 14 days

Inpatient and severe

Ofloxacin 400mg IV 12 hourly (infused over at least 1 hour)
plus
Metronidazole 500mg IV 8 hourly

Switch to oral to complete course as soon as clinically appropriate.

8.2 Gonorrhoea and/or contact with Gonorrhoea

1st Line: Ceftriaxone 500mg IM single dose

or 2nd Line: Cefixime 400mg oral single dose.

plus
azithromycin 1g as a single dose for possible Chlamydia co-infection

8.3 Chlamydia

Treatment follows NHS Borders STI Management Protocol.

Treatment should be initiated without waiting for laboratory information.

Suitable samples
• In men, a first void urine
• In women, undergoing a vaginal examination, a cervical swab
• In women not undergoing a vaginal examination, a first void urine
• A self-taken swab is an alternative for women not undergoing a vaginal examination

Uncomplicated men and women

Azithromycin 1g oral single dose
or
Doxycycline 200mg oral stat then 100mg 12 hourly for 6 days

21
Pregnant women OR risk of pregnancy
Azithromycin is not licensed for use in pregnancy but is very widely used. (Discuss with GUM)

Caution: Erythromycin and amoxicillin have a recognised failure rate hence careful follow-up
necessary. Ofloxacin and doxycycline are contra-indicated in pregnancy.

Erythromycin 500mg oral 12 hourly for 14 days

or, if intolerant to erythromycin
Amoxicillin 500mg oral 8 hourly for 14 days

Treatment of Neonatal chlamydial eye infection

Erythromycin 12.5mg/kg oral 6 hourly for 14 days

8.4 Epididymo-orchitis
All sexually active men should be tested for Chlamydia prior to treatment

Sexual transmission suspected or men under 35, cause unknown

1st line Doxycycline 100mg oral 12 hourly for 14 days
or
2nd line Erythromycin 500mg oral 12 hourly for 14 days

plus
Ceftriaxone 500mg IM single dose

No suggestion of sexual transmission or men over 35, cause unknown

1st line Ofloxacin 400mg oral 12 hourly for 14 days
or
2nd line Ciprofloxacin 500mg oral 12 hourly for 10 days
CSM advice (tendon damage) see BNF

Review at 14 days. If symptoms persist, for further course of antimicrobial treatment.

8.5 Genital Herpes

First Episode
Aciclovir 200mg oral x 5 times a day for 5 days
or Valaciclovir 500mg oral 12 hourly for 5 days
If symptoms are very severe consider a 10 day course
If frequent recurrences seek advice from GUM (01896 663700)

8.6 Vaginal Candidiasis

Fluconazole 150mg oral single dose (not in pregnancy)

or
Clotrimazole pessary 500mg single dose
If frequent recurrences (defined as four episodes of mycologically proven candidiasis
in 12 months) see NHS Borders STI Management Protocol available on the intranet.

8.7 Penile Candidiasis

Clotrimazole cream 1% 8 hourly for 7 days

22
9 URINARY TRACT INFECTIONS

Reference SIGN 88: http://www.sign.ac.uk/pdf/sign88.pdf

Whenever possible, a specimen of urine should be collected for culture and sensitivity testing
before starting antibacterial therapy. The therapy should reflect current local antibacterial
sensitivity patterns.

In general asymptomatic bacteriuria in the elderly should not be treated with antibiotics. “Dip-
stick” results are only helpful in MSU.

Remember genital tract sites e.g. vagina, prostate, may give rise to WBC on specimen
microscopy.

Please contact a Nephrologist immediately if a kidney transplant patient is found to have a

urinary tract infection.

9.1 Simple Urinary Tract Infections

Excludes pregnancy and children

Women and Men

First line: Trimethoprim 200mg oral 12 hourly

or
Second line: Nitrofurantoin 50mg oral 6 hourly. Avoid nitrofurantoin in renal failure (eGFR
less than 60ml/min) due to toxicity & lack of efficacy.

Duration of treatment:
Women ……………………………………………………………………….…3 days
Men ………………………………………………………………… …….…...7 days

Further therapy should be based on sensitivity results

9.2 Catheter specimen

In catheterised patients, the bladder quickly becomes colonised. Microscopy and/or “dip-stick”
testing is unhelpful as WBC, rbc, nitrate and protein may all be positive when the bladder is
colonised.

Catheter urine samples should be sent for culture and sensitivities only if patient is febrile or
systemically unwell and bladder is the likely source.

If possible, remove catheter. Treat only if there is clinical suspicion of bacteraemia and, if
appropriate, after consultation with microbiologist. If treating, the catheter should be changed.

Changing of long term urinary catheter:

• Where patients have developed sepsis related to changing a long-term urinary
catheter, prophylaxis may be considered.
• Previously documented antimicrobial resistance should be considered when choosing
an appropriate antimicrobial.
• The following suggestions are made for empirical use in the absence of antimicrobial
resistance information.

23
First choice
GENTAMICIN
Dose: 3 mg/kg (lean body weight) up to a maximum of 320 mg IV single dose
Second choice
TRIMETHOPRIM
Dose: 200mg orally single dose

9.3 Urinary Tract Infections in Pregnancy

Mid-stream urine sample must be taken. Always treat asymptomatic bacteriuria.

A post-treatment specimen should always be sent.
Initial treatment

Cefalexin 250mg oral 6 hourly for 7 days

9.4 Complicated Urinary Tract Infections

Principally pyelonephritis.
Also includes patients with abnormal renal tract, immunocompromised patients, or history of
recurrent UTI's.

Appropriate urine samples should be taken before commencing antimicrobials.

Initial Treatment

Ciprofloxacin 500mg 12 hourly PO

If nil by mouth, use co-amoxiclav IV first line with or without Gentamicin as below.

Second line

Co-amoxiclav 625 mg 8 hourly PO (1.2g 8 hourly IV if pyelonephritis, nil by mouth or

nausea / vomiting - change to PO once able to tolerate)

plus, if severe add Gentamicin (Extended Interval Dosing - see Appendix i Monitoring
Antimicrobial Dosage) to either ciprofloxacin or co-amoxiclav, above

Treat for 7-14 days

Change treatment, according to sensitivities. Switch to oral, according to sensitivities, when

no nausea, vomiting, fever or sepsis.

24
9.5 Prostatitis

Acute Prostatitis requires immediate treatment.

Chronic Prostatitis requires investigation before antimicrobials are started; only 10% of cases
are caused by infection.

Initial treatment

First line
Ciprofloxacin 500mg oral 12 hourly CSM advice (tendon damage) see BNF

Second line
Trimethoprim 200mg oral 12 hourly

Duration of treatment:
Acute and Chronic Bacterial Prostatitis …………………………….…… 4 to 6 weeks

25
10 RESPIRATORY TRACT INFECTIONS

General ref: NICE Respiratory Tract Infectionhttp://www.nice.org.uk/nicemedia/pdf/CG69QRG.pdf.

10.1 Acute Exacerbations of Chronic Obstructive Pulmonary Disease*

Patients with two or more of the three cardinal signs may benefit from treatment with
antimicrobials

• Increased shortness of breath

• Increased sputum volume
• Purulent sputum

Most patients who have persistent purulent sputum between exacerbations are colonised with
Haemophilus, Streptococcus, Staphylococcus, Moraxella or Pseudomonas species.

Antimicrobials should be tailored against previous isolates where possible, otherwise start
treatment with -

Amoxicillin 500mg oral 8 hourly for 5 to 7 days

Penicillin allergy
Doxycycline 200mg oral on first day then 100mg daily
for a total of 7 days

For treatment failures:

Co-amoxiclav (Amoxicillin/clavulanic acid) 625mg oral 8 hourly for 7 days

If severe
Co-amoxiclav 1.2g IV 8 hourly
Plus
Clarythromycin 500mg IV 12 hourly
(Clarithromycin IV should only rarely be necessary in COPD)

Pseudomonal infections
Ciprofloxacin 750mg oral 12 hourly (use IV route (400mg) only if oral not possible) CSM
advice (tendon damage) see BNF

Note: It is important to distinguish between colonisation/overgrowth and actual infection in

patients with sputum culture positive for Pseudomonas. The patient’s clinical condition should
always be included in the assessment for anti-Pseudomonal antibiotics. Heavy growth of
pure Pseudomonas, repeated positive culture, significant purulence of sputum and presence
of systemic symptoms indicate a greater likelihood of infection as opposed to colonisation /
overgrowth. When colonisation / overgrowth is suspected it is appropriate to delay antibiotics
and continue to review the patient’s clinical progress and/or repeat sputum cultures after an
interval. Resistance to CIPROFLOXACIN is a significant risk in Pseudomonas respiratory
tract infection

*NICE COPD Guideline. http://www.nice.org.uk/nicemedia/pdf/CG012_niceguideline.pdf

Bronchiectasis: See protocol in Borders Joint Formulary

Immunosuppressed Patients: Consult other relevant protocols, e.g. neutropenic sepsis,

HIV.

26
 10.2 Community Acquired Pneumonia

CURB-65 Severity Scores for Community Acquired Pneumonia

Any of:
• Confusion
• Urea >7 mmol/l
• Respiratory rate ≥30/min
• Blood pressure (SBP <90mm Hg or DBP ≤60mm Hg)
• Age ≥65 years

CURB-65 score

0 or 1 2 3 or more

GROUP 2
GROUP 1 GROUP 3
Mortality
Mortality low intermediate Mortality high
(1.5%) (9.2%) (22%)

Treatment options Consider hospital

supervised treatment Manage in hospital as severe
pneumonia
Likely suitable Options may include:
(a) short stay inpatient Assess for ICU admission
for home
(b) hospital supervised especially if
treatment
outpatient CURB-65 score = 4 or 5

Antibacterials
Amoxicillin 500mg to 1g orally 8 Co-amoxiclav 1.2g 8 hourly IV
Amoxicillin hourly plus
500mg to 1g oral 8 plus Clarithromycin 500mg IV 12
hourly for 7 days Clarithromycin 500mg oral 12 hourly
hourly for 7 days
Penicillin allergy Alternative in penicillin allergy
Clarithromycin or, if IV required Clarithromycin 500mg IV 12
500mg oral 12 Amoxicillin 1g IV 8 hourly hourly
hourly for 7 days plus plus
Clarithromycin 500mg IV 12 hourly Vancomycin
See appendix 1
Switch to oral antibiotics as soon as Monitoring Antibiotic Dosage
clinically appropriate
Switch to oral equivalents as
Penicillin allergy or intolerance to soon as
Clarithromycin Clinically appropriate
Discuss with Consultant (vancomycin switches to
Microbiologist doxycyline)
Suggest doxycycline
200mg daily

REMEMBER: Switch from IV oral therapy when clinically stable and by 3 days if RR <25/min,
haemodynamically stable and able to take oral agents.

27
10.2.1 Legionella
Antimicrobial combinations which include clarithromycin will provide cover for Legionella.
Samples for Legionella testing are acute and convalescent sera (clotted blood) and urine for
Legionella antigen.

10.2.2 Pneumonia post influenza

Ref. Thorax, 2007; 62: supp 1.

Hospital treated, non-severe pneumonia, post influenza

Co-amoxiclav 625mg oral tds

or, if IV needed, co-amoxiclav 1.2g tds IV

Penicillin allergy: clarithromycin 500mg oral bd

or, if IV needed, clarithromycin 500mg bd IV

Hospital treated, severe pneumonia, post influenza

Co-amoxiclav 1.2g IV tds
Plus clarithromycin 500mg IV bd

Penicillin allergy: consult microbiologist

10.3 Hospital Acquired Pneumonia

Obtain advice at an early stage.

Contact a Consultant Microbiologist if Pseudomonas or MRSA present or if previously treated
with antimicrobials

Initial treatment
Co-amoxiclav (Amoxicillin / clavulanic acid) 625mg oral 8 hourly

If severe
Co-amoxiclav 1.2g IV 8 hourly
plus
Gentamicin (Extended Interval Dosing See Appendix i Monitoring Antimicrobial Dosage)

Penicillin allergy
Vancomycin (see appendix i monitoring antimicrobial dosage)
plus
Ciprofloxacin 500mg oral 12 hourly

10.4 Aspiration Pneumonia

Co-amoxiclav (Amoxicillin / clavulanic acid) 1.2g IV 8 hourly
Penicillin allergy
Discuss with microbiologist

10.5 Ventilator Acquired pneumonia

Consult ITU protocol

10.6 Tuberculosis

ALL cases of suspected Tuberculosis or other Mycobacterial disease must be referred to the
Respiratory Physician responsible for TB care.

28
11 SKIN AND SOFT TISSUE INFECTIONS

11.1 Cellulitis (not perineum)

Commonly caused by Streptococci, may occasionally involve Staphylococcus aureus.

Non-severe
Flucloxacillin 500mg oral 6 hourly CSM advice (hepatic disorders) see BNF
alone, or plus
Penicillin V 500mg oral 6 hourly

Penicillin allergy
Clarithromycin 500mg oral 12 hourly

Severe
Benzylpenicillin 1.2g IV 4 – 6 hourly
Plus
Flucloxacillin 1g to 2g IV 6 hourly CSM advice (hepatic disorders) see BNF
and consider:
Gentamicin (Extended Interval Dosing. See Appendix i Monitoring Antimicrobial Dosage)

Penicillin allergy – substitute Benzylpenicillin plus Flucloxacillin with:

Vancomycin See Appendix i Monitoring Antimicrobial Dosage

If severe unresponsive cellulitis, consider deeper infections, including necrotising

fasciitis. If this is suspected please discuss with both surgery and microbiology
urgently.

If cellulitis is associated with lymphoedema, refer to NHS Borders Guideline

http://intranet/resource.asp?uid=19446

Orbital Cellulitis

Co-amoxiclav (Amoxicillin / clavulanic acid) 1.2g IV 8 hourly

Penicillin allergy
Cefuroxime 750mg to 1.5g IV 8 hourly
plus
Metronidazole 500mg IV 8 hourly

Skin and soft tissue infections related to drug misuse

Benzylpenicillin 1.2g IV 4 – 6 hourly

Plus
Flucloxacillin 1g to 2g IV 6 hourly CSM advice (hepatic disorders) see BNF

Seek advice from Microbiology

11.2 Diabetic foot

See diabetes protocol on hospital intranet

29
11.3 Necrotising Fasciitis / Streptococcal Toxic Shock Syndrome

Discuss with Consultant Microbiologist

Initial treatment (and for upper limb)

Benzylpenicillin 1.2g to 2.4g IV 4 hourly
plus
Flucloxacillin 1-2g IV 6 hourly
plus
Clindamycin 600mg IV 6 hourly

Initial treatment for lower limb

Tazocin 4.5g IV 8 hourly

plus
Clindamycin 600mg IV 6 hourly

11.4 Surgical Wound Infection

Wounds quickly become colonised, treat and swab only when there are clinical signs of
infection.

Initial treatment
Flucloxacillin 500mg oral 6 hourly for 5 to 7 days
CSM advice (hepatic disorders) see BNF
Penicillin allergy
Clarithromycin 500mg oral 12 hourly for 5 to 7 days

11.5 Traumatic Wounds / Lacerations

Wound infection occurs in 1 – 12% of all non-bite wounds. Antibiotic prophylaxis or tetanus
immunoglobulin is not usually required for simple, clean lacerations.

For high risk tetanus prone wounds (heavily contaminated with soil / faeces or devitalised
tissue) human tetanus immunoglobulin should be given, irrespective of the tetanus
immunisation history of the patient.

A tetanus containing vaccine is given if necessary, according to immunisation history.

Ref: Green Book, Tetanus (chapter 30)

http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/DH_4097254

Treatment of clean lacerations that become infected

Flucloxacillin 500mg oral 6 hourly for 5 to 7 days

CSM advice (hepatic disorders) see BNF

Penicillin allergy
Clarithromycin 500mg oral 12 hourly for 5 to 7 days

Consider antimicrobial prophylaxis if patient is immunocompromised e.g. diabetic, asplenic,

alcohol dependant or laceration is stellate, intra-oral or to the feet. Antibiotics are as for
treatment.

30
Treatment of infected lacerations that were previously contaminated; puncture wounds
or wounds with a significant amount of devitalised tissue

Co-amoxiclav (Amoxicillin / Clavulanic acid) 375 – 625mg oral 8 hourly

Penicillin allergy
Clarithromycin 500mg oral 12 hourly
plus
Metronidazole 400mg oral 8 hourly for 5 to 7 days

Consider antimicrobial prophylaxis in puncture wounds or wounds contaminated with soil,

manure or faeces and wounds with a significant amount of devitalised tissue. Antibiotics are
as for treatment.

11.6 MRSA Skin and Soft Tissue Infections

Cellulitis / febrile but not unstable:

First line
Doxycycline 100mg oral 12 hourly on Day 1, then 100 mg oral 24 hourly
plus
Rifampicin 600mg oral 24 hourly

or

Second line
Trimethoprim 200mg oral 12 hourly
plus
Sodium Fusidate 500mg oral 8 hourly

For all MRSA infections, antibiotic monotherapy should not be given as this can cause rapid
development of resistance.

The only two exceptions to this are Vancomycin and Doxycycline, which in some
circumstances may be prescribed as monotherapy.

Toxic / unstable

Vancomycin For dosing regimen see Appendix i Monitoring Antimicrobial Dosage

11.7 Multiple injuries and/or compound fractures of long bones

Co-amoxiclav 1.2g IV 8 hourly

Penicillin allergy
Discuss with Consultant Microbiologist

REMEMBER Tetanus prophylaxis

31
11.8 Bites

Consider antimicrobial prophylaxis for the following: human bites, bites to the hand, foot or
face, deep/puncture wounds, wounds requiring surgical debridement, bites to high risk
patients e.g. diabetics, immunocompromised, prosthetic valve. The choice of antimicrobial for
prophylaxis is the same as used for treatment.

See Traumatic Wounds / Lacerations above for management of high risk tetanus prone
wounds.

Human, Dog or Cat bites

Co-amoxiclav (Amoxicillin / clavulanic acid) 625mg oral 8 hourly for 5 days

Penicillin allergy, excluding pregnancy and children

Doxycycline 100mg every 12hours
plus
Metronidazole 400mg oral 8 hourly for 7 days

Penicillin allergy in Pregnancy

Erythromycin 500mg every 12 hours
plus
Metronidazole 400mg oral 8 hourly for 7 days

Consult Microbiologist if animal species is other than a dog or a cat

11.9 Herpes

Herpes Simplex (cold sores)

Aciclovir cream 5% applied 5 times daily at onset of episode for 5 – 10 days

Herpes zoster (shingles)

Treatment beneficial if commenced within 72 hours of onset of rash

Aciclovir 800mg oral fives times daily (every four hours) for 7 days

Disseminated Herpes Infection

Discuss with Consultant Microbiologist

Aciclovir 5mg/kg IV 8 hourly

11.10 Leg Ulcers / Pressure Sores / PEG sites

Antimicrobial treatment is ONLY indicated if there is evidence of spreading cellulitis.

Discuss with Consultant Microbiologist

32
Appendix i
Monitoring Antimicrobial Dosage

Gentamicin Extended Interval Dosing for Adults

Intravenous Gentamicin Use in Adults (GGC Guidance Approved SAPG January 2013)

Background
This policy covers the use of intravenous (IV) gentamicin in adults using the Greater Glasgow
and Clyde (GGC) dosing guidance.
The policy is for the use of gentamicin for the treatment of infection only. SAPG
recommendations on gentamicin dosing for surgical prophylaxis are provided elsewhere.
The guidance does not apply to gentamicin use in the following:
o synergistic treatment of endocarditis or Staphylococcal bone infection
o patients treated in Renal units or receiving haemodialysis or haemofiltration
o major burns
o ascites
o age < 16 years
o cystic fibrosis (refer to local guidelines)
o pregnancy (refer to local guidelines)

Contra-indications and cautions

 Contra-indications to gentamicin therapy – hypersensitivity, myasthenia gravis
 Cautions to gentamicin therapy:
o Patients with decompensated liver disease - aminoglycosides are associated with an
increased risk of renal failure.
o Concurrent administration of neurotoxic and / or nephrotoxic agents increases the risk
of gentamicin toxicity. Review therapy and consider amending or withholding
nephrotoxic drugs during gentamicin treatment. Avoid co-administration with the
following:
• neuromuscular blockers
• other potentially nephrotoxic (e.g. NSAIDs and ACE Inhibitors) or
ototoxic drugs
• potent diuretics
• other aminoglycosides
This list is not exhaustive – consult the Summary of Product Characteristics (eSPC)
for a full list (www.medicines.org.uk)
o Chronic Kidney Disease (CKD) Stage 4 or more, known or suspected acute kidney
injury in the previous 48 hours (≥ 50% increase in baseline serum creatinine or oliguria
> 6 hours). If gentamicin is clinically indicated, give one dose as per guidance and
check with microbiology or an infection specialist before giving a second dose.
Prescribing and documentation
 To improve the prescribing of gentamicin, ensure consistency and reduce risk,
standardised charts (agreed nationally) should be used to document the prescription,
administration and monitoring of gentamicin. These should be used for prescribing
treatment doses of gentamicin in conjunction with the existing inpatient prescribing chart
(e.g. kardex) and medical / nursing documentation.
 These charts contain a step-wise approach to safe and effective prescribing and key
points of advice on monitoring, interpreting and re-prescribing.

33
STEP 1: Calculate, prescribe and administer the first dose
 To reduce the risk of mortality, commence gentamicin administration within 1 hour of
recognising sepsis.
 If creatinine is known – use the online calculator (preferred method). The guidelines in
Table 1 (below) can be used if the online calculator is not available. The dose amount and
dosage interval are based on estimated creatinine clearance (Box 1) and actual body
weight.
 If creatinine is not known – give an initial dose of 5 mg/kg gentamicin (maximum 400 mg)
or, if Chronic Kidney Disease (CKD) 5, give 2.5 mg/kg (maximum 180 mg) on advice of
senior staff. Calculate the dose using actual body weight.
 Give the recommended dose by infusion in 100 mL sodium chloride 0.9% over 30 minutes
and ensure the time of administration is noted on the medicine chart.
Box 1: Estimation of creatinine clearance (CrCl)
The following ‘Cockcroft Gault’ equation can be used to estimate creatinine clearance
(CrCl)
[140 – age (years)] x weight (kg) x 1.23 (male) OR x 1.04 (female)
CrCl = ----------------------------------------------------------------------------------------
(mL/min) serum creatinine (micromol/L)
Cautions:
• Use actual body weight or maximum body weight whichever is lower.
For maximum body weight table see
http://www.scottishmedicines.org.uk/files/sapg/Maximum_body_weight_table.pdf
• In patients with low creatinine (< 60 micromol/L), use 60 micromol/L.
• Note: Use of estimated glomerular filtration rate (eGFR) is not recommended.

Table 1: Initial GENTAMICIN doses and dose intervals

Actual body
weight →
40 - 49 kg 50 - 59 kg 60 - 69 kg 70 - 80 kg > 80 kg
Creat Cl
(mL/min) ↓
< 21 2.5 mg/kg (max 180 mg) then take a sample after 24 hours

180 mg 200 mg 240 mg 240 mg 260 mg

21 - 30
48 hourly 48 hourly 48 hourly 48 hourly 48 hourly

200 mg 240 mg 280 mg 300 mg 320 mg

31 - 40
48 hourly 48 hourly 48 hourly 48 hourly 48 hourly

240 mg 280 mg 320 mg 360 mg 400 mg

41 - 50
48 hourly 48 hourly 48 hourly 48 hourly 48 hourly

200 mg 240 mg 280 mg 300 mg 320 mg

51 - 60
24 hourly 24 hourly 24 hourly 24 hourly 24 hourly

240 mg 280 mg 320 mg 360 mg 400 mg

> 60
24 hourly 24 hourly 24 hourly 24 hourly 24 hourly
Caution: If the patient weighs < 40 kg and CrCl is ≥ 21 mL/min, give a single dose of 5 mg/kg
then take a sample 6 – 14 hours after the dose and follow the instructions in Step 2.

34
STEP 2: Monitor creatinine and gentamicin concentrations and reassess
the dosage regimen

Concentrations are meaningless unless the dose & sample times are recorded accurately

If creatinine clearance is ≥ 21 mL/min

 Take a blood sample 6-14 hours after the start of the first gentamicin infusion.
 Record the exact time of all gentamicin samples on the gentamicin prescribing chart AND
on the sample request form.
 Record the serum concentration on the gentamicin prescribing chart.
 Plot the concentration measurement on the graph and reassess the dose / dosing interval as
indicated.
 This will indicate one of 3 options: 1) continue the present dosage regimen
2) adjust the dosage interval
3) withhold and resample after 24 hours

If creatinine clearance is < 21 mL/min

 Take a blood sample 24 hours after the start of the first gentamicin infusion.
 Record the exact time of all gentamicin samples using the gentamicin prescribing chart
AND on the sample request form.
 If therapy is to continue, take additional blood samples at least every 24 hours and give a
further dose once the measured concentration is < 1 mg/L.

35
 STEP 2: Monitor creatinine and gentamicin concentrations and reassess
the dosage regimen

General points

 Document the action taken in the medical notes and on the gentamicin prescribing chart.
 Undertake pre-prescribing checks (Boxes 2 and 3) to assess the risk of renal toxicity and
ototoxicity.
 Prescribe the next dose as appropriate.
 Seek advice from pharmacy or microbiology if you are unsure how to interpret the result or if
the concentrations are very low. Doses up to 600 mg may be required for some patients.
 If a blood sample is not taken, is lost or is taken at wrong time and if there is any concern
about the patient’s renal function, take a sample 20-24 hours after the start of the
gentamicin infusion and wait for the result before giving the next dose. Otherwise, take a
blood sample after the next dose.

If the measured concentration is unexpectedly HIGH or LOW, consider the following:

 Were dose and sample times recorded accurately?
 Was the correct dose administered?
 Was the sample taken from the line used to administer the drug?
 Was the sample taken during drug administration?
 Has renal function declined or improved?
 Does the patient have oedema or ascites?

If in doubt, take another sample before re-prescribing and/or contact pharmacy for advice

STEP 3: Assess daily the ongoing need for gentamicin and signs of toxicity

 Take a further blood sample 6-14 hours after the dose, at least every 2 days.
 If the gentamicin concentration is unexpectedly high or if renal function alters, daily
sampling may be necessary.
 To minimise the risk of toxicity, duration of treatment should normally be limited to 72 hours.
All gentamicin prescriptions that continue beyond 3-4 days of treatment must be discussed
with microbiology or an infection specialist. Consider changing to an oral alternative - refer
to the IV to Oral switch policy.
Box 2: Renal toxicity

 Monitor creatinine daily. Seek advice if renal function unstable (e.g. change in creatinine of >
15-20%).
 Signs of renal toxicity include increase in creatinine or decrease in urine output/oliguria.
 Consider an alternative agent if creatinine is rising or the patient becomes oliguric.
Box 3: Ototoxicity

 Ototoxicity secondary to gentamicin is independent of drug concentration. It is suggested by

any of the following: new tinnitus, dizziness, poor balance, hearing loss or oscillating vision.
 Toxicity is associated with prolonged aminoglycoside use (usually > 10 days but may be > 72
hours) and is secondary to drug accumulation within the inner ear.

 Stop treatment if ototoxicity is suspected and refer to microbiology or an infection specialist for
advice on future therapy.

 If gentamicin continues for > 7 days, consider referring to audiology for assessment.

36
Gentamicin Divided Dosing for Adults

Indication
Divided dose Gentamicin is used in endocarditis and some Gram-positive infections on the
recommendation of the Consultant Microbiologist.

Cautions
Monitor renal, auditory and vestibular function in addition to Gentamicin levels. Caution in
patients receiving other nephrotoxic drugs eg. frusemide.
Gentamicin should be avoided completely in myasthenia gravis.

Adult Dose 1mg/kg by intravenous infusion over 30 minutes in 50-100ml Sodium

Chloride 0.9% or glucose 5%

(use actual body weight to calculate gentamicin dose unless patient is obese [BMI ≥30
kg/m2 ] in which case ideal body weight should be used).

Frequency: Dependent on renal function

eGFR>40 ml/min 12 hourly

eGFR 30-40 ml/min 24 hourly

eGFR <30 ml/min Give first dose then take trough sample after 24h
and await results before redosing

Once causative organisms are known

Dose of Gentamicin and choice of antimicrobial should be tailored to the organisms
isolated; following discussion with the Consultant Microbiologist.

Monitoring Gentamicin Levels

Monitor renal, auditory and vestibular function in addition to Gentamicin levels.

Levels are usually taken around the third dose. Paired blood samples are required.

The first sample or trough sample is taken immediately before the dose.

The second sample or peak sample is taken 60 minutes after the completion of the infusion,
from a different site.

Document the exact time the dose is given and the times the samples are taken.

Type of Infection Peak Level Trough Level

Streptococcal endocarditis 3 to 5mg/litre Less than 1mg/litre

Staphylococcal infection 5 to 8mg/litre Less than 2mg/litre

Acceptable levels are as above.

If levels are within range and renal function stable repeat levels twice weekly. Monitor
daily if poor or changing renal function.

If levels are out of range Contact Microbiology or Pharmacy for advice on dose adjustment

37
Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion

Background
This policy covers the use of intravenous vancomycin prescribed as an intermittent (pulsed)
infusion. This can be used for treatment or prophylaxis.
This policy does not apply to the use of vancomycin in patients treated in Renal units or
receiving haemodialysis or haemofiltration.

Contra-indications and cautions

 Contra-indications to vancomycin therapy – hypersensitivity
 Cautions for vancomycin therapy:
o To avoid the risk of “red-neck/red-man syndrome”, pain or muscle spasm, ensure
that the administration rate is not faster than 500 mg per hour.

o Concurrent administration of neurotoxic and / or nephrotoxic agents increases the

risk of vancomycin toxicity. Review therapy and consider amending or withholding
nephrotoxic drugs during treatment with vancomycin. Where possible, avoid co-
administration with the following:
o amphotericin
o potent diuretics
o aminoglycosides
o NSAIDs
o ACE inhibitors

o The above list is not exhaustive – consult the Summary of Product Characteristics
eSPC for a full list (www.medicines.org.uk).

o Due to potential ototoxicity, vancomycin should be avoided in patients with

previous hearing loss.

Prescribing and documentation

 To ensure consistency, reduce risk and improve the prescribing of vancomycin,

standardised charts should be used where available to document the prescription,
administration and monitoring of intermittent vancomycin infusions. These should be used
in conjunction with the existing inpatient prescribing chart (e.g. kardex) and medical /
nursing documentation.

 These charts contain a step-wise approach to safe and effective prescribing and key
points of advice on monitoring, interpreting and re-prescribing.

38
Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion

STEP 1: Prescribe the loading dose and maintenance dosage regimen

 To reduce the risk of mortality, commence vancomycin administration within 1 hour of

recognising sepsis.
 If creatinine is known – use the online calculator (preferred method). The guidelines
(below) in Table 1 (loading dose) and Table 2 (maintenance dose) can be used if the
online calculator is not available. The dose amount and dosage interval are based on
estimated creatinine clearance (Box 1) and actual body weight.
 If creatinine is not known – calculate and prescribe a loading dose based on actual body
weight (Table 1). Calculate the maintenance dose once the creatinine is available.

Box 1: Estimation of creatinine clearance (CrCl)

The following ‘Cockcroft Gault’ equation can be used to estimate creatinine clearance
(CrCl)

[140 – age (years)] x weight (kg) x 1.23 (male) OR x 1.04 (female)

CrCl = --------------------------------------------------------------
(mL/min) serum creatinine (micromol/L)

Cautions
• Use actual body weight or maximum body weight whichever is lower.
For maximum body weight table see
http://www.scottishmedicines.org.uk/files/sapg/Maximum_body_weight_table.pdf
• In patients with low creatinine (< 60 micromol/L), use 60 micromol/L.
• Note: Use of estimated glomerular filtration rate (eGFR) is not recommended

LOADING DOSE

Table 1: Initial vancomycin LOADING dose

Volume of
Actual body Duration of
Dose sodium chloride
weight infusion
(0.9%)*
< 40 kg 750 mg 250 mL 90 minutes
40 – 59 kg 1000 mg 250 mL 2 hours
60 – 90 kg 1500 mg 500 mL 3 hours
> 90 kg 2000 mg 500 mL 4 hours

* Glucose 5% may be used in patients with sodium restriction.

39
Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion

STEP 1: Prescribe the loading dose and maintenance dosage regimen

MAINTENANCE DOSAGE REGIMEN

 Give the first maintenance infusion 12, 24 or 48 hours after the loading infusion according
to dose interval provided by the online calculator or Table 2 (below).

Table 2: Vancomycin MAINTENANCE dosage regimen

VANCOMYCIN PULSED INFUSION - INITIAL MAINTENANCE DOSAGE GUIDELINES

Volume of sodium
CrCl (mL/min) Dose amount Dose Interval
chloride (0.9%)*
< 20 500 mg over 1 hour 250 mL 48 hours

20 - 29 500 mg over 1 hour 250 mL 24 hours

30 - 39 750 mg over 1.5 hours 250 mL 24 hours

40 - 54 500 mg over 1 hour 250 mL 12 hours

55 - 74 750 mg over 1.5 hours 250 mL 12 hours

75 - 89 1000 mg over 2 hours 250 mL 12 hours

90 - 110 1250 mg over 2.5 hours 250 mL 12 hours

>110 1500 mg over 3 hours 500 mL 12 hours

* Glucose 5% may be used in patients with sodium restriction. Doses up to 2000 mg can be
diluted in 500 mL fluid.
 The daily dose can be split into 3 equal doses and given 8 hourly. This approach is
especially useful for patients who require high doses as it produces higher trough
concentrations.
For example, 1500 mg 12 hourly (3000 mg per day) could be prescribed as 1000 mg 8
hourly and
750 mg 12 hourly (1500 mg per day) as 500 mg 8 hourly.

STEP 2: Monitor the vancomycin concentration and reassess the dosage

regimen

Concentrations are meaningless unless the dose & sample times are recorded accurately

 Due to wide variability in the handling of vancomycin, early analysis of a vancomycin

concentration is required to ensure that the dosage regimen is appropriate.
 Take a trough sample (pre-dose) within 48 hours of starting therapy then every
2 - 3 days, or daily if the patient has unstable renal function.
 Monitor creatinine daily.
 Record the exact time of all vancomycin samples on the vancomycin prescribing chart
AND on the sample request form.
 If renal function is stable, give the next dose before the trough result is available. If renal
function is deteriorating, withhold until the result is available then follow the advice in Table
3.

40
 Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion

STEP 2: Monitor the vancomycin concentration and reassess the dosage

regimen

Target vancomycin concentrations

 Target trough concentration range: 10 – 20 mg/L
 If the patient is seriously ill (severe or deep-seated infections), the target range is
15 – 20 mg/L. If the measured concentration is < 15 mg/L, consider increasing the dose
amount or reducing the dosage interval (see 8 hourly dosing above).
 If the patient is failing to respond, seek advice from microbiology or an infection specialist.

Adjustment of the vancomycin dosage regimen

 Always check that the dosage history and sampling time are appropriate before
interpreting the result.
 Seek advice from pharmacy or microbiology if you need help to interpret the result.

If the measured concentration is unexpectedly HIGH or LOW, consider the following:

 Were the dose and sample times recorded accurately?
 Was the correct dose administered?
 Was the sample taken from the line used to administer the drug?
 Was the sample taken during drug administration?
 Has renal function declined or improved?
 Does the patient have oedema or ascites?

Table 3: Adjustment of Vancomycin Dosage Regimen

Vancomycin concentration Suggested dose change

Increase the dose by 50% and consider reducing the

<10 mg/L
dosage interval or seek advice

If the patient is responding, maintain the present

dosage regimen.
10 – 15 mg/L
If the patient is seriously ill, consider increasing the
dose amount or reducing the dosage interval to
achieve a trough level of 15 – 20 mg/L.

15 – 20 mg/L Maintain the present dosage regimen

>20 mg/L Stop until <20 mg/L then seek advice

If in doubt, take another sample before modifying the dosage regimen and / or contact pharmacy
for advice

41
Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion

STEP 2: Monitor the vancomycin concentration and reassess the dosage

regimen

General points
 Record the exact times of all measured concentrations on the vancomycin prescription
chart.
 Undertake pre-prescribing checks (Box 2) to assess the risk of toxicity
 Reassess the dose and continue or prescribe a dosage change
 Document the action taken in the medical notes
 Review the need for vancomycin daily.

Box 2: Toxicity

 Monitor creatinine daily. Seek advice if renal function is unstable (e.g. a change in
creatinine of > 15-20%)
 Signs of renal toxicity include increase in creatinine or decrease in urine output /
oliguria
 Consider an alternative agent if creatinine is rising or the patient becomes oliguric.
 Vancomycin may increase the risk of aminoglycoside induced ototoxicity – use
caution if co-prescribing.

42
APPENDIX ii

PREGNANCY AND ANTIMICROBIALS

When considering treatment with an antimicrobial agent during pregnancy, the following
factors should be considered:

• The severity of the maternal infection

• The effects of any fever present on the pregnancy
• The consequences or failing to treat the mother
• The potential fetotoxicity of the drugs to be used

Where possible, the results of culture and sensitivity tests should be available before making a
treatment choice.

If infections are treated empirically then penicillins and cephalosporins are the agents of
choice.

For further advice or information contact Consultant Microbiologist and Pharmacy and refer to
BNF.

Antimicrobial (systemic) Effect (trimester of administration)

Penicillins Not known to be harmful

e.g. Amoxicillin
Erythromycin Not known to be harmful
Tetracyclines Maternal liver failure (2, 3)
Adverse effects on fetal teeth and bones (1,2,3)
Aminoglycosides Not teratogenic. However, potential for nephro-and ototoxicity
e.g. Gentamicin (2, 3)
Avoid unless essential
Careful monitoring of levels in mother essential
Cephalosporins Not known to be harmful
Trimethoprim Avoid – teratogenic risk (folate antagonist) (1)
Nitrofurantoin Neonatal haemolysis (3)
Quinolones Avoid-theoretical risk of Arthropathy (1, 2, 3)
e.g. Ciprofloxacin Seek advice from a Consultant Microbiologist
and Nalidixic Acid
Metronidazole Avoid high dose regimes (over 1.5g daily)
Aciclovir Not known to be harmful
Manufacturer advises to use only if benefits outweigh risks
Treatment of choice, when indicated, in preference to other
anti-virals

43
APPENDIX iii

ANTICOAGULANTS AND ANTIMICROBIALS

The following antimicrobials are known to interact with oral anticoagulants.

Advice should be sought from a Consultant Haematologist or Pharmacist preferably before, or

within 24 hours of, prescribing.

Anticoagulant effect may be REDUCED by

• Rifampicin

Anticoagulant effect may be ENHANCED by

• Ciprofloxacin/Ofloxacin
• Fluconazole/Itraconazole
• Erythromycin/Clarithromycin
• Metronidazole
• Sulphonamides
• Nalidixic Acid
• Tetracyclines
• Trimethoprim

Refer to BNF for further information.

If a patient on oral anticoagulants requires antimicrobial therapy, problems are least likely to
be encountered with the penicillins or the first and second-generation cephalosporins such as
Cefalexin or Cefuroxime.

However, clinical experience indicates that oral broad-spectrum agents such as amoxicillin
may alter the INR, possibly through an effect on the gut bacterial flora.

Other factors such as diet and level of physical activity can also affect a patient’s response to
oral anticoagulants. Close monitoring is advised during periods of illness.

In general, when prescribing an antimicrobial:

Keep the course length to a minimum.

If the course is to be longer than five days, therapy should be discussed with a Consultant
Microbiologist or Consultant Haematologist.

The INR should be checked on day 2 of antimicrobial therapy and advice taken as to whether
further checks are required.

44
APPENDIX iv

SURGICAL PROPHYLAXIS GUIDELINES

The goals of prophylaxis administration of antimicrobials to surgical patients are to:
• Reduce the incidence of surgical site infection
• Use antimicrobials in a manner that is supported by evidence of effectiveness
• Minimise the effects of the antimicrobials on the patient’s normal gut flora
• Minimise adverse effects
• Cause minimum changes to the patient’s host defences

All IV doses should be given within 60 minutes prior to skin incision and as close to time of
incision as practically possible.

Doses are usually intravenous and generally the same as those used therapeutically.

Single doses only to be prescribed unless otherwise stated.

Further doses are only required in prolonged procedures (>4h) or if there is significant blood
loss (>1500ml in adults and 25ml/kg in children).

Contaminated or dirty, infected wounds require treatment courses not prophylaxis

Pregnant patients: Gentamicin should be avoided in pregnancy. Cefuroxime is suitable

alternative.
General Surgery

Appendectomy Gentamicin 3mg/kg IV (maximum 320mg)

plus Metronidazole 500mg IV
Colorectal surgery
Gentamicin 3mg/kg IV (maximum 320mg)
plus Metronidazole 500mg IV
Upper GI Surgery e.g. cholecystectomy
*(Not recommended for laparoscopic Gentamicin 3mg/kg IV (maximum 320mg)
procedure unless ‘High Risk’ see below)

Endoscopic retrograde Gentamicin 160mg IV

Cholangiopancreatography (ERCP)
**(Recommended for ‘High Risk’ patients
only see below)
Mastectomy/wide local excision/ axillary Flucloxacillin 1g IV
node sampling/breast or, if penicillin allergy,
biopsy/microdochectomy/tissue expander Gentamicin 3mg/kg IV (maximum 320mg)
prosthesis
Hernia repair with or without mesh Prophylaxis not recommended

Haemorrhoidectomy, including stapled Gentamicin 3mg/kg IV (maximum 320mg)

haemorrhoidopexy plus Metronidazole 500mg IV
PEG insertion Preferred choice: Co-amoxiclav 1.2g IV

Alternative: cefuroxime 750mg

MRSA Carriage The Infection Control Team should be
consulted regarding possible eradication
therapy for adults undergoing general
surgery who are identified with MRSA or
Staph. Aureus.
MRSA positive patients should receive cover
that includes a glycopeptide (teicoplanin
400mg IV).

SIGN 104 July 2008, updated April 2014.

45
*‘High Risk’ intraoperative cholangiogram, bile spillage, conversion to laparotomy,
acute cholecystitis / pancreatitis.jaundice, pregnancy, immunosuppression, prosthesis
insertion
** ‘High Risk’ pancreatic pseudocyst, immunosuppression, incomplete biliary drainage

Urology
Transrectal prostate biopsy Ciprofloxacin 500mg oral 60 minutes before
procedure
Transurethral resection of prostate Gentamicin 160mg IV

TURBT (Local practice) Gentamicin 160mg IV

Obstetrics and Gynaecology

Caesarean Section Cefuroxime 1.5g IV + metronidazole
500mg IV.

Or, in immediate (type 1) beta-lactam

sensitivity
Clindamycin 900mg IV

Gynaecology majors, including PFRs Gentamicin 3mg/kg IV (maximum 320mg)

plus Metronidazole 500mg IV

Termination of pregnancy Metronidazole 1g oral or PR 2 hours before

surgery followed by Azithromycin 1g oral
single dose (unless pre-operative screening
has ruled out chlamydial infection) with
administration of Misoprostol
Transvaginal tapes Gentamicin 3mg/kg IV (maximum 320mg)
plus Metronidazole 500mg IV

Orthopaedic Surgery
Total Joint Arthroplasty (antibiotic loaded Cefuroxime 1.5g IV
cement is also recommended in addition
to IV antibiotics) Or, in immediate (type 1) beta-lactam
sensitivity
Teicoplanin 400mg IV
plus Gentamicin 3mg/kg IV (maximum
320mg)
Other arthroplasty procedures Flucloxacillin 1g IV plus
Gentamicin 3mg/kg IV (maximum 320mg)

All intramedullary nails Or in Penicillin allergy

Teicoplanin 400mg IV
plus Gentamicin 3mg/kg IV (maximum
320mg)
Other internal fixations / operations Prophylaxis at discretion of Orthopaedic
Consultant

46
Complex, open fractures with extensive Co-amoxiclav 1.2g IV 8 hourly for three
soft tissue injury doses.

penicillin allergy
Teicoplanin 400mg IV 12 hourly for 3 doses
plus gentamicin 3mg/kg IV (maximum
320mg)

Follow treatment guidelines if ongoing

infection suspected

Oral Surgery
Wisdom teeth extraction Preferred choice: Co-amoxiclav 1.2g IV
High risk patients (at discretion of oral
Alternative: cefuroxime 750mg IV
surgeon)

Gastrointestinal Endoscopy
PEG insertion Co-amoxiclav 1.2g IV

Or, in penicillin allergy, teicoplanin 400mg

IV

Variceal banding (planned) Co-amoxiclav 1.2g IV

Or, in minor penicillin allergy, cefotaxime 2g

IV. Or, in immediate (type 1) beta-lactam
sensitivity, teicoplanin 400mg IV

Gastrointestinal bleed (not strictly Co-amoxiclav 1.2g IV 8 hourly

prophylaxis)
Or, in minor penicillin allergy, cefotaxime 2g
IV 8 hourly. Or, in immediate (type 1) beta-
lactam sensitivity, vancomycin IV (see
appendix 1: monitoring antibiotic dosage)
plus ciprofloxacin 400mg IV 12 hourly
(consult Microbiologist if patient has been
receiving a quinolone as SBP prophylaxis).

Scottish Intercollegiate Guidelines Network Surgical Prophylaxis Guidelines

http://www.sign.ac.uk/pdf/sign104.pdf

Scottish Antimicrobial Prescribing Group. Antibiotic Prophylaxis in Surgery. June 2009.

http://www.scottishmedicines.org

British Society of Gastroenterology.Antibiotic prophylaxis in gastrointestinal endoscopy.

Gut 2009; 58: 869-880.

47
APPENDIX v

GUIDELINES FOR THE PROTECTION OF THE ADULT ASPLENIC PATIENT

Patients with functional hyposplenia or with impaired immune function should always be
referred to a Consultant Haematologist.

Patients who have their spleen removed as a result of trauma or surgery should be
considered for the following therapy.

Vaccination Schedule
Elective splenectomy 4-6 weeks pre-operatively

If this is not possible then up to 2 weeks before

procedure

Unplanned splenectomy At least 2 weeks post-operatively

Vaccines
Haemophilus influenzae type b One dose Hib/MenC vaccine (Menitorix) followed
Meningococcal by one dose MenACWY conjugate vaccine
(Menveo) one month later
Pneumococcal Pneumococcal polysaccharide vaccine
(Pneumovax II)
Repeat at 5 yearly intervals
Influenza Recommended yearly for seasonal protection

Prophylactic Antimicrobials

Antimicrobials should be given for at least two years post splenectomy and consideration
given to life long prophylaxis

Phenoxymethylpenicillin (Pen V) 500mg twice daily

Penicillin allergy – Clarithromycin 250mg twice daily

Antimicrobial Treatment

In addition to prophylaxis, a supply of antimicrobials may be kept at home and used

immediately should symptoms of raised temperature, malaise or shivering illness occur.

Co-amoxiclav (Amoxicillin/clavulanic acid) 375mg 8 hourly for 7 days

Penicillin allergy
Clarithromycin 500mg 12 hourly for 7 days

Counselling

Patients should be given advice about general infection risk, foreign travel, further vaccines,
food hygiene, malaria prophylaxis, animal and tick bites and the need for prompt referral to
hospital if signs and symptoms of a febrile infection occur.

Patients should be given a patient information leaflet and a “no spleen” card for the patient to
carry.

48
APPENDIX vi

PROPHYLAXIS OF INFECTIVE ENDOCARDITIS

In the past, people at risk of infective endocarditis* have been offered antibiotics when
they have certain medical or dental procedures. NICE** has recommended a change in
practice, so now antibiotics should only be offered if the procedure is at a site where
there is a suspected infection. This is because medical and dental procedures are no
longer thought to be the main cause of endocarditis, and taking antibiotics carries its
own risk.

*Adults and Children with the following structural cardiac conditions are ‘at risk’ of
developing infective endocarditis

• acquired valvular heart disease with stenosis or regurgitation

• valve replacement
• structural congenital heart disease, including surgically corrected or palliated structural
conditions but excluding isolated atrial septal defect, fully repaired ventricular septal
defect or fully repaired patent ductus arteriosus, and closure devices that are judged to
be endothelialised
• hypertrophic cardiomyopathy
• previous endocarditis

Advice
Offer people at risk of infective endocarditis clear and consistent information about
prevention, including:
• the benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic
prophylaxis is no longer routinely recommended
• the importance of maintaining good oral health
• symptoms that may indicate infective endocarditis and when to seek expert advice
• the risks of undergoing invasive procedures, including non-medical procedures such
as body piercing or tattooing

When to offer prophylaxis

Do not offer antibiotic prophylaxis against endocarditis:

• to people undergoing dental procedures

• to people undergoing non-dental procedures at the following sites
• upper and lower gastrointestinal tract
• genitourinary tract; this includes urological, gynaecological and obstetric procedures
and childbirth
• upper and lower respiratory tract; this includes ear, nose and throat procedures and
bronchoscopy

Do not offer chlorhexidine mouthwash as prophylaxis against infective endocarditis to people

at risk undergoing dental procedures.

Managing infection
Investigate and treat promptly any episodes of infection in people at risk of infective
endocarditis to reduce the risk of endocarditis developing.

Offer an antibiotic that covers organisms that cause infective endocarditis if a person at risk of
infective endocarditis is receiving antimicrobial therapy because they are undergoing a
gastrointestinal or genitourinary procedure at a site where there is a suspected infection.

** NICE clinical guideline 64 Prophylaxis against infective endocarditis March 2008

http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11938

49
APPENDIX vii
GUIDANCE ON SWITCHING ANTIBIOTICS FROM IV TO ORAL

Advantages of prompt switch to oral therapy include

• Reduction in hospital acquired bacteraemia caused by infected lines. Peripheral lines
should be changed every 72 hours, or earlier if they look infected, and removed as
soon as they are no longer required.
• Improved patient comfort and mobility
• Oral doses are more convenient to administer, saving medical and nursing time
• Possibility of earlier discharge from hospital
• Improved use of resources

Considerations for early switch to oral therapy COMH (Review at 24 to 48 hours)

C Clinical improvement observed

O Oral route not compromised

• Suitable oral formulation available

• No vomiting or severe diarrhoea
• No swallowing disorder, patient fully conscious (contact pharmacy for advice on
antimicrobials via PEG / NG tube)

M Markers show a trend to normal

• Temperature above 36ºC and below 39ºC, preferably normal for at least 24
hours
• Heart rate less than 90 beats per minute
• Blood pressure stable
• Respiratory rate less than 20 breaths per minute
• White cell count, where available, shows trend to normal

H High risk / deep seated infections and/or a senior clinician or consultant microbiology
has specifically advised a longer duration of IV therapy
Certain infections may appear to respond promptly but warrant prolonged IV therapy to
optimise response and minimise risk of relapse. Discuss with a consultant
microbiologist before switching patients with high risk/deep seated infections
For deep-seated infections an initial two High risk infections need prolonged IV therapy,
weeks of therapy may be needed. such as
Examples include
• Staphylococcus aureus bacteraemia
• Liver abscess • Necrotising soft tissue infections
• Osteomyelitis • Neutropenic sepsis
• Septic arthritis • Infected implants/prosthetics
• Empyema • Meningitis
• Cavitating pneumonia • Intracranial abscess
• Mediastinitis
• Endocarditis
• Exacerbations of cystic fibrosis
• Inadequately drained abscesses and
empyema

If the patient deteriorates on oral therapy consider return to IV and / or discuss with the
Consultant Microbiologist.

Consult Antimicrobial Guideline or contact microbiology for advice on choice of oral therapy.
50
In general:

IV Agent Oral
Amoxicillin Amoxicillin 500mg-1g 8 hourly
Ciprofloxacin Ciprofloxacin 500mg 12 hourly
(750mg 12 hourly if pseudomonas
suspected)
Clarithromycin Clarithromycin 500mg 12 hourly
Clindamycin Clindamycin 300-450mg 6 hourly
Co-amoxiclav Co-amoxiclav 375-625mg 8 hourly
Flucloxacillin Flucloxacillin 500mg-1g 6 hourly
Gentamicin None equivalent – change as indicated by
sensitivities or microbiology advice
Metronidazole Metronidazole 400mg 8 hourly
Rifampicin Rifampicin 0.6-1.2g daily in 2-4 divided doses
Teicoplanin/Vancomycin/Meropenem/Tazocin None equivalent – change as indicated by
sensitivities or microbiology advice

*The above table applies only to patients with normal renal function. Doses should be
adjusted according to severity of infection. Check for microbiology sensitivity results.

References:

1. http://www.bsac.org.uk/pyxis
2. Sevinc F et al. Early switch from intravenous to oral antimicrobials:
Guidelines implementation in a large teaching hospital JAC 1999; 43:601-666

51
APPENDIX viii

PROTOCOL FOR MANAGEMENT OF PATIENTS WITH NEUTROPENIC SEPSIS AT BORDERS GENERAL

HOSPITAL

Introduction

Patients with fever and neutropenia are at major risk of developing potentially fatal
septicaemia. Immediate treatment with intravenous antibiotics is ESSENTIAL if the patient is
to be protected from this complication.

Patients at risk of neutropenic sepsis

• Receiving myelotoxic chemotherapy

• Condition which leads to a reduction in neutrophil numbers and / or function
• May be inpatients anywhere in BGH or may be outpatients
• NB: Patients receiving chemotherapy as day cases are instructed to seek medical
advice if they become unwell and / or develop a fever. If these patients or their
relatives or GP / nurse make contact with duty medical / nursing staff at BGH it is
ESSENTIAL that they are advised to attend without delay

Definition of neutropenic sepsis

Fever of 38°C or above on two separate occasions at least one hour apart, or a single episode
of fever >38.5°C

PLUS

Neutrophils of less than1.0 x 10 9/1 or higher than that but likely to decline to 1.0 or less.

Clinical Assessment

Take a careful history with special regard to -

Date of any last chemotherapy

Symptoms of infections (e.g. cough, dysuria)
Any previous episodes of fever
Any severe allergies to antibiotics (not simply minor rash)

Full clinical examination, special points are –

Check Hickman line sites

Examine mouth and perineum (no digital rectal examination)
Fundoscopy for retinal haemorrhage (platelets may be low)
Patient needs to be WEIGHED for calculation of Gentamicin dose (see below)

Investigations
Swab any infected site, including Hickman line site
MSU
Chest X-Ray
Sputum (where available) for culture
Stool culture and Clostridium difficile toxin if diarrhoea present
Repeat FBC, U+E LFT CRP Coagulation screen, Group and Save
Blood cultures – peripheral plus from any central line if present
Pulse oximetry, arterial blood gases if saturation <92%

52
Treatment

Set up IV drip and ensure adequate fluid resuscitation. Typically patients will require up to 3
litres of crystalloid in 24 hours. Colloid may be needed to support blood pressure.

IMMEDIATE IV antibiotics once blood cultures are taken

Piperacillin/tazobactam (Tazocin) 4.5G 6 HOURLY (check no Penicillin allergy)

In addition to above:
Rx Gentamicin extended interval dosing (see Appendix i – Monitoring Antimicrobial
Dosage)

Note: Patients receiving nephrotoxic chemotherapy, e.g. Carboplatin or Cisplatin should

not receive Gentamicin. Consult Microbiologist or Haematologist for advice.

If known severe beta-lactam allergy seek advice from Consultant Microbiologist. A

combination of Glycopeptide (Vancomycin or Teicoplanin) with Gentamicin and Metronidazole
may be appropriate. If the beta-lactam reaction consists of a rash only it should be safe to
replace piperacillin/tazobactam + Gentamicin with Ceftazidime 2g TDS + Gentamicin.

If clinically obvious Hickman line infection add teicoplanin 400mg daily (plus additional dose
at 12 hours). (Check dose with microbiologist as in some cases10mg/kg required). Discuss
with Consultant Haematologist with respect to removing the line.

Rx Oxygen as needed.

Careful fluid balance – daily weight where possible.

Neutropenic patients on long term methotrexate treatment should be given folinic acid rescue.
See Rheumatology Service Guidelines.

INFORM THE DUTY CONSULTANT HAEMATOLOGIST REGARDLESS OF TIME OF DAY

OR NIGHT.

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APPENDIX ix RENAL IMPAIRMENT AND ANTIBIOTICS

For patients receiving renal dialysis (haemodialysis, CAPD) refer to manufacturers’ recommendations and renal unit guidelines.
Contact pharmacy for advice.
For renal replacement therapy on ITU see ITU guidelines.

Drug/Dose in normal Degree of renal impairment (CrCl) and dosage adjustment Comments
renal function
Amoxicillin PO 20-50 ml/min 10-20 ml/min <10 ml/min
500mg 8 hourly dose as in normal dose as in normal renal function 250-500mg 8 hourly
renal function

Amoxicillin IV 20-50 ml/min 10-20 ml/min <10 ml/min Sodium content of Injection
500mg-1g 8 hourly dose as in normal dose as in normal renal function 250-1g 8 hourly (max. 6g 3.3 mmol/g vial of Amoxil
renal function per day in endocarditis)

Benzylpenicillin 20-50 ml/min 10-20 ml/min <10 ml/min 600mg contains

600mg – 3.6g 6 hourly dose as in normal 600mg-2.4g 6 hourly 600mg-1.2g 6 hourly 1.68mmol of
renal function Sodium
Ciprofloxacin PO
20-50ml/min
250-750mg 12 hourly 10-20 ml/min <10 ml/min
dose as in normal
50-100% of normal dose 50% of normal dose
renal function
Ciprofloxacin IV 20-50ml/min
100-400mg 12 hourly dose as in normal 10-20 ml/min <10 ml/min
renal function 50-100% of normal dose 50% of normal dose
Clarithromycin IV/PO
30-50ml/min 10-30 ml/min <10 ml/min
500mg 12 hourly
dose as in normal 250-500 mg 12 hourly 250-500mg 12 hourly
renal function
Co-amoxiclav PO
30-50ml/min 10-30 ml/min <10ml/min
375-675mg 8 hourly
dose as in normal dose as in normal renal function dose as in normal renal
renal function function

30-50ml/min 10-30ml/min <10ml/min

Co-amoxiclav IV dose as in normal 1.2g 12 hourly 1.2g stat followed by
1.2g 8 hourly renal function 600mg
8 hourly or 1.2g 12 hourly

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 Drug/Dose in normal Degree of renal impairment (CrCl) and dosage adjustment Comments
renal function
20-50 ml/min 10-20 ml/min <10 ml/min
Erythromycin dose as in normal dose as in normal renal function 50-75% of normal dose
500mg qds renal function

20-50 ml/min 10-20 ml/min <10 ml/min

Flucloxacillin PO
dose as in normal dose as in normal renal function dose as in normal renal
250mg-500mg 6 hourly
renal function function
10-20 ml/min <10 ml/min
20-50 ml/min Sodium content of injection
Flucloxacillin IV dose as in normal renal function dose as in normal renal
dose as in normal 2.26mmol/g
250mg – 2g 6 hourly function (max. total daily
renal function
dose of 4g)
20-50 ml/min 10-20 ml/min <10 ml/min
Fluconazole
dose as in normal dose as in normal renal function 50% of normal dose
50-400mg daily
renal function
10-20 ml/min <10
Meropenem IV 20-50ml/min 500mg – 1g 12 hourly 500mg – 1g 24 hourly
500mg-1g 8 hourly 500mg-2g 12 hourly or 500mg 8 hourly

Metronidazole PO 20-50 ml/min 10-20 ml/min <10 ml/min

200-400mg 8 hourly dose as in normal dose as in normal renal function dose as in normal renal
renal function function
20-50 ml/min 10-20 ml/min <10 ml/min
Metronidazole IV Sodium content 14mmol in
dose as in normal dose as in normal renal function dose as in normal renal
500mg 8 hourly 500mg/100ml injection
renal function function
Penicillin V 20-50 ml/min 10-20 ml/min <10 ml/min
250mg –1000mg 6 dose as in normal dose as in normal renal function dose as in normal renal
hourly renal function function
20-50 ml/min 10-20 ml/min <10 ml/min
Piperacillin/tazobactam dose as in normal 4.5g 8-12 hourly or 4.5g 12 hourly or
4.5g 6-8 hourly renal function 2.25g 6 hourly 2.25g 8 hourly
>27 ml/min 15-27 ml/min <15ml/min th
Trimethoprim 200mg 12 hourly for three days From Martindale 37 ed.
dose as in normal 100mg 12 hourly
200mg 12 hourly renal function then 100mg 12 hourly
1 rd
Suggested doses from the Renal Drug Handbook, 3 ed (2009), C. Ashley & A. Currie, eds) unless otherwise stated.

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