Antibiotic Guidelines
Before using these guidelines, please review the following points:
- Allergies. Ask about allergies, before giving antibiotics. Writing 'NKDA' is unhelpful. The next person does not know whether you asked the question, or wrote it as a 'default' position, because you could not find it out, and got frustrated. If you and/or the patient does not know, say that. Also, if it is not clear whether a patient is really (and seriously) allergic to a drug, do not give it. Talk to a senior, and think about an alternative antibiotic
- Review previous microbiology results on your hospital's results server (Alerts for MRSA, Clostridium Difficile or an ESBL-producing coliforms are particularly important to identify)
- Check renal and liver function, before starting antibiotics. Both can be affected by antibiotics
- These (and most) guidelines are based on normal renal function. When using GENTAMICIN or VANCOMYCIN, use the calculators on your hospital's intranet
- Irrespective of renal function, give the first dose of GENTAMICIN (5 mg/kg) as a 30 minute infusion (should not normally exceed a maximum dose of 400mg)
- IV VANCOMYCIN must be administered in a dilute solution slowly, over at least 60 minutes (maximum rate of 10 mg/minute for doses >500 mg) to avoid 'Red Man Syndrome'
- Check levels of either drug after 48h, then every 48h. To avoid nephrotoxicity, do not give more GENTAMICIN if trough levels are >1 mg/L, or VANCOMYCIN if > 10 mg/L. Both can also cause ototoxicity. This can be irreversible
- Intravenous antibiotics should be reviewed at 48 hours (request this on the drug card). Ie, at 48h ask yourself, are they working? Can the patient be switched to oral antibiotics?
- Oral drugs should be written up for 5 days, then reviewed (request this on the drug card)
- For a septic patient, the attending doctor must ensure that the first dose of the appropriate antibiotic(s) is given WITHIN ONE HOUR of that thought. It is not enough to write it up. Check availability of that drug on that ward, and check nurses understand urgency of delivering drug to patient. This is especially true for 4 conditions: suspected meningitis, septic arthritis, neutropenic sepsis, and severe sepsis (of any cause). Ie, if you think of one of these diagnoses, treat it immediately
- Are the drugs (especially the important ones) being given when the patient leaves the ED? In one study, 20% of drugs written up were not given by the nurses, usually because the drug is not available on that ward. You will not necessarily be told that a drug is not being given. So, check the drugs cards every day
Penicillin allergy
Nausea, vomiting or diarrhoea do not, by themselves, constitute an allergic reaction. Therefore they are not a contraindication for Penicillin use. An anaphylactic reaction related to histamine release occurs 30-60mins after administration of a penicillin, symptoms may include erythema or pruritis, angioedema, hypotension or shock, urticaria, wheezing, rhinitis
ERTAPENEM or MEROPENEM is recommended as an alternative to penicillin for some indications. HOWEVER if there is a history of an anaphylactic reaction, or an accelerated allergic reaction DO NOT prescribe these drugs. Please discuss alternative antibiotics with a Microbiologist. Remember penicillins (and cephalosporins) can also be nephrotoxic (as they can induce an interstitial nephritis)
Antibiotic resistance
This information is updated regularly on the UK's Health Protection Agency's website (HPA): Antimicrobial Resistance and Prescribing in England, Wales and Northern Ireland, 2008 (pdf)
NOTE: THESE ARE ANTIBIOTIC GUIDELINES USED IN UHCW, COVENTRY. YOUR HOSPITAL'S MAY BE DIFFERENT
Bacterial Meningitis
IV CEFTRIAXONE 2g od (Penicillin Allergy: IV CHLORAMPHENICOL 1g qds)
Note 1: CEFTRIAXONE has no activity against Listeria Monocytogenes
Note 2: Therefore, if patient is a neonate, or >65 years old, or immunocompromised, add IV AMOXYCILLIN 2g 4hrly
Note 3: Consult microbiologist for all lengths of treatment in meningitis, and the need for further tests on CSF samples, eg TB or viral PCR
Cellulitis / Wound Infection
Non severe
PO FLUCLOXACILLIN 500mg-1g qds (Pencillin Allergy: PO DOXYCYCLINE 200mg od OR PO ERYTHROMYCIN 500mg qds)
Note: If known/suspected MRSA, use DOXYCYCLINE instead of FLUCLOXACILLIN. Ensure sensitivities reviewed
Severe
IV FLUCLOXACILLIN 2g qds + IV CLINDAMYCIN 600mg qds + IV GENTAMICIN 5mg/kg od
(Penicilin Allergy: IV VANCOMYCIN 1g bd + IV CLINDAMYCIN 600mg qds + IV GENTAMICIN 5mg/kg od)
Note 1: Review need for GENTAMICIN daily
Note 2: If known/suspected MRSA, use VANCOMYCIN instead of FLUCLOXACILLIN. Ensure sensitivities reviewed
Animal bites
PO CO-AMOXICLAV 625mg tds (Penicillin Allergy: CLINDAMYCIN 450mg qds + PO CIPROFLOXACIN 500mg bd)
Note: Consider tetanus immunisation in ALL patients and possibility of RABIES in travellers
Line infections
Line exit site infection (associated with peripheral line removal)
PO DOXYCYCLINE 200mg od (Penicillin Allergy: PO DOXYCYCLINE 200mg)
Line-associated sepsis
Urgently consider line removal. Take blood culture before starting antibiotics
IV FLUCLOXACILLIN 2g qds + IV GENTAMICIN 5mg/kg od (Penicillin Allergy: IV VANCOMYCIN 1g bd + IV GENTAMICIN 5mg/kg od)
Note 1: Review blood culture results at 24 hours
Note 2: Review need for GENTAMICIN daily
Note 3: If known / suspected MRSA use VANCOMYCIN instead of FLUCLOXACILLIN
Gastroenterology
Clostridium Difficile
Mild
Stop precipitating antibiotic if possible. No specific treatment may be indicated
PO METRONIDAZOLE 400mg tds (14d)
Moderate
PO METRONIDAZOLE 400mg tds (14d). If no response after 48 hours, change to PO VANCOMYCIN 125mg qds (14d)
Severe
PO VANCOMYCIN 125mg qds + IV METRONIDAZOLE 500mg tds (14d)
Note: Refer to gastroenterologist/surgeon
Relapses
First relapse: use the same antibiotic used to treat the initial episode
Subsequent relapses: PO VANCOMYCIN 125mg qds (14d); followed if necessary by pulsed doses of oral VANCOMYCIN: 125mg bd for a week, 125mg OD for a week, then 125mg every 2-3 days for 2-8 weeks, in an attempt to restore normal colonic flora
Community-Acquired intra-abdominal infections
IV CO-AMOXICLAV 1.2g tds + IV GENTAMICIN 5 mg/kg od (Penicilin Allergy: IV ERTAPENEM 1g od + IV GENTAMICIN 5mg/kg od)
Note: Review need for GENTAMICIN daily
Acute cholecystitis
IV TAZOCIN 4.5g tds (Penicillin Allergy: IV MEROPENEM 1g tds). Don't forget TAZOCIN is a combination of a penicillin PIPERACILLIN and TAZOBACTAM. So an alternative antibiotic may be necessary, if the patient has a significant drug penicillin allergy
Acute cholangitis and Acute Hospital-Acquired intra-abdominal infections
IV TAZOCIN 4.5g tds iv + IV GENTAMICIN 5mg/kg od (Penicillin Allergy: IV MEROPENEM 1g tds + IV GENTAMICIN 5mg/kg od). Don't forget TAZOCIN is a combination of a penicillin PIPERACILLIN and TAZOBACTAM. So alternative antibiotics may be necessary, if the patient has a significant drug penicillin allergy
Note: Review need for GENTAMICIN daily
Acute pancreatitis
MEROPENEM 1g tds
Note: IV antibiotics only indicated if there is evidence of >30% necrosis on CT scan
Necrotising fasciitis
SURGICAL DEBRIDEMENT IS AN URGENT PRIORITY
IV BENZYLPENICILLIN 2.4g qds + IV CLINDAMYCIN 600mg qds + IV GENTAMICIN 5mg/kg od (Penicillin Allergy: IV MEROPENEM 2g tds + IV CLINDAMYCIN 600mg qds)
Note: Review need for GENTAMICIN daily
Necrotising fasciitis involving the Abdomen or Pelvis
IV MEROPENEM 2g tds + IV CLINDAMYCIN 600mg qds (Penicillin Allergy: IV MEROPENEM 2g tds + IV CLINDAMYCIN 600mg qds)
Other sepsis
Sepsis - source unclear
IV BENZYLPENICILLIN 1.2g qds + IV GENTAMICIN 5mg/kg od (Penicillin Allergy: IV VANCOMYCIN 1g bd + IV GENTAMICIN 5mg/kg od)
Septic arthritis
SEND JOINT ASPIRATE BEFORE STARTING ANTIBIOTICS
IV FLUCLOXACILLIN 2g qds + IV CEFTRIAXONE 2g od + PO RIFAMPICIN 600mg bd (Penicillin Allergy: IV VANCOMYCIN 1g bd + IV MEROPENEM 1g tds + PO RIFAMPICIN 600mg bd)
Note: Review treatment with microbiologist after 48 hours with culture result
Neutropenic sepsis
IV TAZOCIN 4.5 g tds + IV GENTAMICIN 5 mg/kg od (7 mg/kg , if very unwell); If previous ESBL producer, use MEROPENEM 1g tds instead of TAZOCIN (reduce frequency of MEROPENEM in renal failure). Don't forget TAZOCIN is a combination of a penicillin PIPERACILLIN and TAZOBACTAM. So alternative antibiotics may be necessary, if the patient has a significant drug penicillin allergy
(Penicillin allergy: IV GENTAMICIN 5mg/kg od + IV CIPROFLOXACIN 400mg bd + IV TEICOPLANIN 600mg bd for first 3 doses, then od)
Note: contact specialist team ASAP
Infective endocarditis
Discuss with microbiologist for advice on investigation and treatment
Renal
Cystitis (uncomplicated), with no recent infections or antibiotics
PO TRIMETHOPRIM 200mg bd OR NITROFURANTOIN 50mg qds (caution in renal impairment)
Cystitis (complicated)
PO CO-AMOXICLAV 625mg tds (PENICILLIN ALLERGY: PO CIPROFLOXACIN 500mg bd)
Acute Pyelonephritis
IV CO-AMOXICLAV 1.2g tds + IV GENTAMICIN 5mg/kg od (Penicillin Allergy: IV ERTAPENEM 1g od + IV GENTAMICIN 5mg/kg od)
Note: Review treatment with Microbiologist at 48 hours
Patients with known ESBL 'coliform' colonisation
Note: Check GENTAMICIN sensitivity first, if resistant discuss with Microbiologist
Source likely UTI, and patient well
IV GENTAMICIN 5mg/kg od
If source not UTI, or patient is septic/unwell
IV ERTAPENEM 1g od + IV GENTAMICIN 5mg/kg od
Note 1: Review treatment with GENTAMICIN daily
Note 2: Review treatment after 5 days
Respiratory
Infective exacerbation of COPD
PO AMOXYCILLIN 500mg tds (Penicillin Allergy: PO DOXYCYCLINE 200mg od)
Note: If previous recent episodes please contact Microbiology for advice
Community acquired pneumonia (CAP); CURB-65 score (0-1?Home; 2 admit; 3 = Sen RV)
CAP (outpatient)
PO AMOXICILLIN 500mg tds (Penicillin Allergy: PO ERTHYROMYCIN 500mg qds)
Note: Complete 7 days treatment
CAP (hospital admission, non-severe)
PO AMOXICILLN 500mg tds + PO ERYTHROMYCIN 500mg qds (Penicillin Allergy: PO ERYTHROMYCIN 500mg qds)
Note: If atypical pathogen suspected please refer to respiratory physician for advice
CAP (hospital admission, severe)
IV CO-AMOXICLAV 1.2g tds + IV ERYTHROMYCIN 500mg qds (Penicillin Allergy: IV ERTAPENEM 1g od + IV ERYTHROMYCIN 500mg qds)
Notes: change to oral after 48hrs if patient improving; some infections (eg Legionella) may require 10-14 days treatment; IV macrolides require central line, or large bore IV cannula
(Community-Acquired) Aspiration Pneumonia
IV CO-AMOXICLAV 1.2g tds (Penicillin Allergy: IV ERTAPENEM 1g od iv)
Hospital-Acquired Pneumonia (HAP)/No antibiotics since admission
IV CO-AMOXICLAV 1.2g tds + IV GENTAMICIN 5mg/kg od (Penicilin Allergy: IV MEROPENEM 1g tds + IV GENTAMICIN 5mg/kg od)
Note: Review need for GENTAMICIN daily
HAP/Received antibiotics since admission
IV TAZOCIN 4.5g tds + IV GENTAMICIN 5mg/kg od (Penicillin Allergy: IV MEROPENEM 1g tds + IV GENTAMICIN 5mg/kg od). Don't forget TAZOCIN is a combination of a penicillin PIPERACILLIN and TAZOBACTAM. So alternative antibiotics may be necessary, if the patient has a significant drug penicillin allergy
Note: Review need for GENTAMICIN daily
Depts of Microbiology + Pharmacy, UHCW (September 2008)