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Last updated: Hypothermia
on May 21, 2013

Antibiotic Guidelines

Introduction:


Prescribing Advice

  • Please 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 - ie, say 'uncertain'. If there are none, say 'nil'. These are far stronger statements.  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
  • GENTAMICIN or VANCOMYCIN
    • 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 ill 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
    • severe sepsis (of any cause)
  • Ie, if you think of one of these diagnoses, treat it immediately. Do not wait for the FBC

  • 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

Note

  • These are the antibiotic guidelines used in UHCW, Coventry. Your hospital's may be different

 

 


Abdominal Infections:


Community acquired intra-abdominal infections

  • IV CO-AMOXICLAV  1.2g tds & IV GENTAMICIN 5mg/kg od
  • (Penicillin Allergy: IV ERTAPEMENEM 1g od & IV GENTAMICIN 5mg/kg od)
    Notes: review treatment after 5 days; review need for gentamicin daily 

Acute cholecystitis

  • IV TAZOCIN 4.5g tds
  • (Penicillin Allergy: IV MEROPENEM 1g tds)
    Note: review treatment after 5 days 

Cholangitis and Acute Hospital acquired intra-abdominal infections

  • IV CO-AMOXICLAV 1.2g tds & IV GENTAMICIN 5mg/kg od
  • (Penicillin Allergy: IV MEROPENEM 1g tds & IV GENTAMICIN 5mg/kg od)
    Notes: review treatment after 5 days; review need for gentamicin daily

Pancreatitis

  • IV MEROPENEM 1g tds
  • (Penicillin Allergy: IV MEROPENEM 1g tds)
    Note: antibiotics only indicated if there is evidence of >30% necrosis on CT scan 

Spontaneous bacterial peritonitis (SBP)

  • Developed whilst on ciprofloxacin prophylaxis: IV TAZOCIN 4.5g tds for 5 days
  • Not previously receiving antibiotic prophylaxis: IV CO-AMOXICLAV 1.2g tds


Clostridium Difficile

Mild (= Type 5, 6 or 7 on Bristol Stool Chart; and <3 motions/day and normal WBC)

  • Stop precipitating antibiotic if possible
  • No specific treatment may be indicated
  • PO METRONIDAZOLE 400mg tds for 14 days if specific treatment indicated

 

Moderate (= 3-5 motions/day; and WBC 10-15,000)

  • PO METRONIDAZOLE 400mg tds for 14 days. If no response after 48 hours, change to PO VANCOMYCIN 125mg qds for 14 days

 

Severe, Level A (≥ 5 motions/day; and one of the following: dehydration, WBC >15,000, Temp > 38.5)

  • PO VANCOMYCIN 125mg qds for 14 days

 

Severe, Level B (= A + hypotension, partial ileus, CT scan evidence of severe colitis)

  • PO VANCOMYCIN 500mg qds for 14 days plus IV METRONIDAZOLE 500mg tds 
  • Also refer to Gastroenterologist and/or Surgeon today

 

Severe, Level C (= A + complete ileus or toxic megacolon)

  • As for B. But Vancomycin to be given via a nasogastric tube or rectal installation
  • Consider PO PREDNISOLONE 20-40mg or IV METHYLPREDNISOLONE 500mg od
  • Do ABG (lactate?)
  • Refer to Gastroenterologist and/or Surgeon urgently
  • Consider colectomy – best performed before serum lactate rises >5

 

Relapses

  • Use PO VANCOMYCIN 125mg qds 10-14 days, followed if necessary by this regime: 125mg bd for a week, 125mg od for a week and then 125mg every 2-3 days for 2 to 8 weeks in an attempt to restore normal colonic flora
  • Use the same antibiotic used to treat the initial episode

 

Respiratory Tract Infections:


Infective exacerbation of COPD

  • PO AMOXYCILLIN 500mg tds
  • (Penicillin Allergy: PO DOXYCYCLINE 200mg od)
    Notes: complete 7 days treatment; if previous recent episodes please contact Microbiology for advice 

Pneumonia use CURB 65 score

  • The guidelines below concern common bacterial causes of pneumonia. Rarer bacterial (eg TB, Legionella), viral (eg CMV), fungal or other (eg Pneumocystis cariini) have quite different treatments
  • If you suspect any of these - especially in a patient on immunosuppression, chemotherapy or who may be immunocompromised (especially HIV) - then you will need senior respiratory, microbiology and infectious disease advice 

Community acquired pneumonia (CAP)

CAP (outpatient)

  • PO AMOXYCILLIN 500mg tds
  • (Penicillin Allergy: PO CLARITHROMYCIN 500mg bd)
    Note: complete 7 days treatment
     

CAP (hospital admission non severe)

  • PO AMOXYCILLIN 500mg tds po & PO CLARITHROMYCIN 500mg bd
  • (Penicillin Allergy: CLARITHROMYCIN 500mg bd)
    Notes: review treatment after 5 days; if atypical pathogen suspected please refer to respiratory physician for advice
     

CAP (hospital admission severe)

  • IV CO-AMOXICLAV 1.2g tds & IV CLARITHROMYCIN 500mg bd
  • (Penicillin Allergy: IV ERTAPENEM 1g od & IV CLARITHROMYCIN 500mg bd)
    Notes: review treatment after 5 days; change to oral after 48hrs if   patient improving; some infections (e.g. Legionella) may require 10-14 days treatment 

Community Acquired Aspiration Pneumonia

  • IV CO-AMOXICLAV 1.2g tds
  • (Penicillin Allergy: IV ERTAPENEM 1g od)
    Note: review treatment after 5 days 


Hospital Acquired Pneumonia (HAP)

Hospital Acquired Pneumonia (HAP) (NO antibiotics since admission)

  • IV CO-AMOXICLAV 1.2g tds & IV GENTAMICIN 5mg/kg od
  • (Penicillin Allergy: IV MEROPENEM 1g tds & IV GENTAMICIN 5mg/kg 24 hourly)
    Note: review treatment after 5 days; 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)
    Notes: review treatment after 5 days; review need for gentamicin daily

Skin and Soft Tissue Infections:


Necrotising fasciitis

PLEASE NOTE 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 & IV GENTAMICIN 5mg/kg od)
    Note: review need for gentamicin daily 

Wound Infection / Cellulitis

ALWAYS CONSIDER NECROTISING FASCIITIS AS AN ALTERNATIVE DIAGNOSIS, ESPECIALLY IF PAIN IS MAJOR FEATURE

Non severe

  • PO FLUCLOXACILLIN 500mg-1g qds
  • (Penicillin Allergy: PO  DOXYCYCLINE 200mg od OR PO ERYTHROMYCIN 500mg qds)
    Notes: review treatment after 5 days; 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
  • (Penicillin Allergy: IV VANCOMYCIN 1g bd & IV CLINDAMYCIN 600mg qds & IV GENTAMICIN 5mg/kg od)
    Notes: review treatment after 5 days; review need for gentamicin daily; if known / suspected MRSA use Vancomycin instead of Flucloxacillin 

Animal bites

  • PO CO-AMOXICLAV 625mg tds
  • (Penicillin Allergy: PO CLINDAMYCIN 450mg qds & PO CIPROFLOXACIN 500mg bd)
    Notes: review treatment after 5 days; consider tetanus immunisation in ALL patients and possibility of RABIES in travellers 

Line associated sepsis

  • IV FLUCLOXACILLIN 2g qds & IV GENTAMICIN 5mg/kg od
  • (Penicillin Allergy: IV VANCOMYCIN 1g bd & IV GENTAMICIN 5mg/kg od)
    Notes: review blood culture results at 24 hours; review need for gentamicin daily; if known / suspected MRSA use Vancomycin instead of Flucloxacillin; urgently consider line removal (ring specialist looking after patient); take blood culture before starting antibiotics 

Line exit site infection (associated with peripheral line removal)

  • PO DOXYCYCLINE 200mg od
  • (Penicillin Allergy: PO DOXYCYCLINE 200mg od).
    Note: review treatment after 5 days

Urinary Tract Infections:


Cystitis (uncomplicated)

  • No recent infections or antibiotics
  • PO TRIMETHOPRIM 200mg bd OR PO NITROFURANTOIN 50mg qds [caution in renal impairment]
    Note: review treatment after 3 days for women and 5 days for men; in a male, always investigate (ie renal US ± cystoscopy), looking for a structural cause; in a female, investigate if not of child-bearing age, or change in pattern of UTI, or very unwell 

Cystitis (complicated)

  • PO CO-AMOXICLAV 625mg tds; investigate as above 

Outpatient/or imminent discharge

  • PO CIPROFLOXACIN 500mg bd
    Notes: In patient: please contact Microbiologist eg previous treatment failures or antibiotics; review recent Microbiology results and treat accordingly. If no results available consider above regimen; review treatment at 5 days; investigate as above 

Pyelonephritis / urinary sepsis

  • 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; investigate as above 

Patients with KNOWN ESBL“COLIFORM” colonisation

  • Check gentamicin sensitivity first, if resistant discuss with Microbiologist 

Source likely UTI

  • IV GENTAMICIN 5mg/kg od
  • (Penicillin Allergy: IV GENTAMICIN 5mg/kg od)
    Note: review treatment after 5 days

 If source not UTI or patient is septic

  • IV ERTAPENEM 1g od & IV GENTAMICIN 5mg/kg od
  • (Penicllin Allergy: IV ERTAPENEM 1g od & IV GENTAMICIN 5mg/kg od)
    Note: review treatment after 5 days

Other Infections:


Bacterial Meningitis

  • IV CETRIAXONE 2g od
  • (Penicillin Allergy: IV CHLORAMPHENICOL 1g qds; normally 50mg/kg/day in 4 divided doses)
  • CEFTRIAXONE HAS NO ACTIVITY AGAINST LISTERIA MONOCYTOGENES
    Notes: if patient is >65 years old OR IMMUNOCOMPROMISED add IV AMOXYCILLIN 2g 4 hourly; consult microbiologist for all lengths of treatment in meningitis, and the need for further tests on CSF samples, e.g. TB or viral PCR 

Sepsis – SOURCE UNCLEAR

  • IV BENZYLPENICILLIN 1.2g qds & IV GENTAMICIN 5mg/kg od
  • (Penicillin Allergy: IV VANCOMYCIN bd & IV GENTAMICIN 5mg/kg od)
    Note: review treatment after 5 days 

Septic arthritis

  • IV FLUCLOXACILLIN 2g qds & IV CEFTRIAXONE 2g od & PO RIFAMPICIN 600mg bd
  • (Penicillin Allergy: IV VANCOMYCIN 1g bd & PO RIFAMPICIN 600mg bd & IV MEROPENEM 1g tds)
    Notes: please send joint aspirate before starting 

Neutropenic sepsis

  • Please refer to your Trust's neutropenic sepsis policy 

Infective endocarditis

  • Please discuss with microbiologist for advice on investigation and treatment