HSE SE Antibiotic Guidelines 2012 Booklet
Content
Guidelines for the
empiric use of
antimicrobials
in adults
HSE South East Hospital Network
June 2012
Review Date: June 2013
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Acknowledgement: Gentamicin and Vancomycin Algorithims
page 19 & 21 adapted from original algorithims kindly
provided by Beaumont/Connolly Hospital Antimicrobial
Stewardship Committee in 2011.
Issued by:
Dr. M. Hickey & Dr. D. Keady June 2006
Revised by:
Dr. M. Hickey June 2007
Revised by:
Dr. M. Hickey, Dr. M. Doyle &
Dr. B. Carey April 2008
Revised by:
Dr. M. Hickey, Dr. M. Doyle &
Dr. B. Carey June 2009
Revised by:
Dr. M. Hickey & Dr. M. Doyle June 2010
Revised by:
HSE SE Antimicrobial Stewardship Group
June 2011
Revised by:
HSE SE Antimicrobial Stewardship Group
June 2012
Review Date: June 2013
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Table of Contents
Page No.
General Guidance
2-3
Restricted and Reserve Antimicrobials
4
MRSA
5
Urinary Tract Infection
6
Respiratory Tract Infection
7-12
Endocarditis & Intra-abdominal Infections
12
Gastro-intestinal Infection
13
Septicaemia & Neutropenic Sepsis
14
Bone and Joint Infections
15
Skin and Soft tissue Infections
15
Central Nervous System
16
ENT infections
16
Genital Tract Infection
17
Gentamicin
18-19
Glycopeptides: Vancomycin, Teicoplanin
20-21
Switch from IV to PO
Oral Bioavailability and Relative Costs
22
23-24
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
1
2
Where possible indicate intended duration of therapy at point of initial prescribing. Review IV antimicrobial
therapy daily.
Document indication for therapy and intended duration in medical record. Note these guidelines are intended
for empiric therapy. Rationalise when microbiology results become available.
Piperacillin-tazobactam and co-amoxiclav provide good anaerobic cover. Concurrent metronidazole is
NOT required unless there is gross faecal contamination – e.g. faecal peritonitis. Treatment of aspiration
pneumonia does NOT require addition of metronidazole to either of these antibiotics.
Some antibiotics e.g. ciprofloxacin, fusidic acid and metronidazole have excellent oral
bioavailability and the oral route should be used where possible. IV formulations of these should only be
used if the patient is not absorbing or unable to have oral medications.
2.
3.
4.
5.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
NB: The prescriber should always check prescribing information such as cautions,
contraindications, interactions and side effects when considering antimicrobial therapy. Ensure
information on antimicrobial prescribing, including risks and side effects associated with
antimicrobial treatment, is available to patients or their legal guardians.¹
1.
GENERAL GUIDANCE
3
For oral switch guidelines see pg 22. Oral switch is usually to PO formulation of same antibiotic where
available, except IV penicillin to PO amoxicillin as oral absorption of penicillin is very poor.
Penicillin allergy: obtain & document proper history. If IgE mediated allergic reaction (e.g.
anaphylaxis, angioneurotic oedema, immediate urticaria) avoid all beta-lactams. If rash only, a cephalosporin
may be considered. Erythromycin is often NOT a good substitute.
Flucloxacillin and other betalactams such as co-amoxiclav, piperacillin-tazobactam, cephalosporins and
meropenem do not cover MRSA.
Risk of Clostridium difficile associated with all antibiotic use. Particular risk with all fluroquinolones (e.g.
levofloxacin and ciprofloxacin), clindamycin and cephalosporins.
7.
8.
9.
10.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Oral switch – consider when patient is afebrile and infection parameters are settling for 48 hours and normal
oral absorption. Generally NOT appropriate in meningitis, endocarditis, febrile neutropenia or acute
osteomyelitis/septic arthritis.
6.
Restricted/Reserve Antimicrobials:
A Cochrane review has found that reserving access to selected antimicrobials is the most effective
10
component of any Antimicrobial Stewardship Programme.
Below is the list of Restricted and Reserve antimicrobials for the SE Acute Hospital Network.
These antimicrobials should only be prescribed when this is in line with the recommendations of this
guideline or following discussion with the Clinical Microbiologist.
Indication for therapy and any discussions/advice from the Clinical Microbiologist should be
documented accurately in patient’s medical record.
Restrictions are in place which limit access to these Antimicrobials. Please refer to South East Acute
Hospital Network Guidelines for use of Reserve and Restricted Antimicrobials for details.
Restricted Antimicrobials
IV Piperacillin/Tazobactam
IV Ceftriaxone
IV Ciprofloxacin
IV/PO Levofloxacin
IV Chloramphenicol
IV/PO Clindamycin
IV Teicoplanin
IV Vancomycin
IV/PO Linezolid
IV Meropenem
*Reserve Antimicrobials
IV Cefotaxime
IV Ceftazidime
IV Erythromycin
IV Ofloxacin
IV Colistin
IV Daptomycin
IV Tigecycline
Antifungals
Liposomal Amphotericin B
Anidulafungin
Caspofungin
Voriconazole
Posaconazole
* Reserve antimicrobials should only be prescribed when recommended by a
Consultant and following discussion with the Clinical Microbiologist.
4
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
MRSA
(Meticillin Resistant Staphylococcus aureus)
Infection with MRSA should be suspected if:
•
Patient has previously been colonized with MRSA.
(Please check patients notes or check laboratory
enquiry for ‘SIF code’)
•
Recent hospitalization (within 12 months)
•
Transfer from another hospital or long term care
facility.
•
Other situation where increased clinical suspicion
of MRSA (Please refer to Policy on Control and
Prevention of Meticillin Resistant Staphylococcus
aureus (MRSA) in Acute Hospitals in the HSE/SE.
November 2009 for additional information)²
If MRSA infection is suspected, consider
including a glycopeptide (Vancomycin or
Teicoplanin, see page 20) in the empiric treatment
regimen.
MRSA eradication: Please refer to Policy on Control
and Prevention of Meticillin Resistant Staphylococcus
aureus (MRSA) in Acute Hospitals in the HSE/SE.
November 2009.²
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
5
6
Urinary Tract
Infections³
Condition
Antibiotic
Comments
For patients with catheter associated UTIs,
antibiotics are unlikely to resolve the UTI
unless the catheter is removed. If systemic
sepsis suspected treat as per Pyelonephritis.
Piperacillin-tazobactam 4.5g TDS for 1014 days or gentamicin (see page 18 for dosing
regimen).
Ciprofloxacin 500-750mg BD PO for
2-6 weeks.
Catheter associated
UTI
Pyelonephritis
Prostatitis
Relapse common. Follow up advised. Check
antimicrobial sensitivity where possible.
Send blood cultures and MSU. Rationalise
therapy as soon as possible. Check culture
and antimicrobial sensitivity results.
Patients with recurrent UTIs may have
resistant organisms. Use 7-10 days treatment
in males.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Refer to recent culture results.
If septicaemic: as for pyelonephritis
Nitrofurantoin is not appropriate if creatinine
First line: Nitrofurantoin MR 100mg BD PO
clearance is < 50 ml/min.
for 5 days
Second line: Co-Amoxiclav 625mg TDS PO for 3 days In pregnancy nitrofurantoin may also be used
but it should be avoided at term.
Hospital acquired or
recurrent UTI or
complicated UTI
Lower urinary tract
infection (uncomplicated)
7
COMMUNITY ACQUIRED PNEUMONIA
Condition
Antibiotic
Comments
CURB-65 score should be used with caution
in younger patients as it may underestimate
severity in these patients.
Community Acquired Pneumonia:
Assess severity using CURB-65 score as per
BTS guidelines:
Confusion (new onset)
Urea >7mmol/L
RR≥30/min
BP - hypotensive: SBP <90mmHg or DBP
≤60mmHg
Age ≥ 65 years
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Respiratory Tract Community Acquired
Infections
Pneumonia
These guidelines are not aimed at:
(a) Patients with known predisposing conditions such as cancer or immunosuppression admitted
with pneumonia to specialist units such as oncology, haematology, palliative care, infectious
disease units or AIDS units
(b) Adults with non pneumonic LRTI, including illnesses labelled as acute bronchitis, acute
exacerbations of COPD or “chest infections”
Based on “British Thoracic Society guidelines for the management of
4
community acquired pneumonia in adults: Update 2009.”
8
Community
Acquired
Pneumonia
Levofloxacin 500mg PO/IV OD (12
hourly if severe)
Legionellosis
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
IV route to be used if oral absorption
unreliable. Early oral switch where possible.
Microbiology: Send blood cultures,
sputum, urine for pneumococcal antigen.
7 days appropriate antibiotic therapy is
recommended.
Co-amoxiclav 1.2g tds IV plus clarithromycin
Microbiology: Send blood cultures, sputum
500mg bd IV.
(requesting legionella culture), urine for
(If legionella strongly suspected consider adding pneumococcal antigen and legionella antigen,
levofloxacin)
CRP.
Penicillin allergy (NOT IgE mediated reaction
Consider switch to PO antibiotics as soon as
/anaphylaxis): cefuroxime 750mg-1.5g tds
clinical improvement occurs and patient is
IV plus clarithromycin 500mg bd IV.
apyrexial for 24 hours.
Severe IgE mediated reaction/anaphylaxis
7-10 days appropriate antibiotics is
to penicillin: levofloxacin 500mg PO/IV OD
proposed. This may need to be extended to
(12 hourly if severe).
14-21 days according to clinical judgement.
High severity
(CURB65 = 3-5)
15 - 40% mortality
Amoxicillin 500mg-1.0g tds PO plus
clarithromycin 500mg bd PO.
(IV if PO administration not possible.)
Penicillin allergy: PO doxycycline
Comments
No microbiological tests required. 7
days appropriate antibiotic therapy is
recommended.
Moderate Severity
(CURB65 = 2)
9% mortality
Antibiotic
Amoxicillin 500mg tds PO. (IV if PO
administration not possible.)
Penicillin allergy: clarithromycin 500mg BD
or doxycycline 200mg OD PO loading dose
then 100mg OD PO.
Condition
Low severity
(CURB65 = 0-1)
<3% mortality
9
Intravenous co-amoxiclav
and macrolide
Oral amoxicillin
and macrolide
Oral amoxicillin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
CURB-65 score should be used with caution in younger patients as it may underestimate severity in these patients
Inpatient
management
Inpatient
management
Outpatient
management
High risk
3-5 points
Intermediate risk
2 points
Low risk
0 or 1 point
CURB65 score
New onset mental confusion
Urea>7 mmol/L
Respiratory rate ≥ 30/min
Systolic blood pressure <90mmHg and/or
diastolic blood pressure ≤60mmHg
Age ≥65 years
BTS-recommended therapy for Community Acquired Pneumonia
(Taken from J Antimicrob Chemother 2012; 65: page 612) 4
10
Respiratory
Tract
Infections
Comments
If patient is considered to be high risk
for MRSA, consider adding Vancomycin
For confirmed legionellosis see page 8.
Consider legionella risk. In at risk patients
send urine for legionella antigen and add
clarithromycin empirically. Send sputum for
Legionella culture, if possible
Send sputum for culture if possible
If patient is considered to be high risk
for MRSA, consider adding Teicoplanin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Penicillin allergy: if NOT IgE
mediated/anaphylaxis and if pneumonia is not severe
consider cefuroxime 1.5g TDS IV.
Severe IgE mediated reaction/anaphylaxis to
penicillin: Levofloxacin 500mg PO/IV OD (12
hourly if severe).
If risk factors for MDR pathogens see page 11.
More than 4 days since admission :
Piperacillin-tazobactam 4.5g TDS IV
Penicillin allergy (NOT IgE mediated reaction
/anaphylaxis): Cefuroxime 750 mg -1.5g TDS IV.
Severe IgE mediated reaction/anaphylaxis to penicillin:
Levofloxacin 500mg PO / IV OD. (12 hourly if severe).
Within 4 days of admission & no recent antibiotics:
Co-amoxiclav 625mg TDS PO or 1.2g TDS IV
for 8 days.
Hospital acquired
pneumonia 6
Antibiotic
Patients from nursing home/chronic care
nursing facility/recent hospitalisation refer to
algorithm page 11.
Condition
Health care
associated
pneumonia5
≥2 Risks for MDR
Treat for MDR Pathogens
See HAP p.10
0 Risks for MDR
Treat as severe CAP
See CAP p.8
≥1 Risk for MDR
Treat for MDR Pathogens
See HAP p.10
Yes (CURB65 score 3 or >)
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Patients with HCAP should be identified and then divided on the basis of severity of illness to guide initial therapy. Patients in each group are then further divided based on whether
they have risk factors for drug-resistant (MDR) pathogens that include: recent antibiotic therapy in the past 6 months, recent hospitalization in the past 3 months, the presence of immune
suppression, and poor functional status as defined by activities of daily living. CAP, community-acquired pneumonia; HAP, hospital-acquired pneumonia.
*Adapted from Brito V, et al. Current Opinion in Infectious Diseases 2009, 22:316-325
0-1 Risks for MDR
Treat for common
CAP Pathogens
See CAP p.8
No (CURB65 score mild or moderate)
Severe pneumonia (Based on CURB65 score)
Presence of risk factors for multi-drug resistant (MDR) pathogens
(recent antibiotics, recent hospitalization, poor functional status, immune suppression)
AND
Assess severity of illness (Use CURB65 score)
HCAP present: Patient from nursing home/chronic care facility, recent hospitalization
Algorithm for healthcare-associated pneumonia (HCAP) therapy*
11
12
Co-amoxiclav 1.2g TDS IV for 7-10
days.
First line: Co-amoxiclav 1.2g TDS IV
Second line: Piperacillin-tazobactam 4.5g TDS
IV. Consider addition of gentamicin
First line: Piperacillin-tazobactam 4.5g TDS
IV. Consider addition of gentamicin
Second line: Meropenem 1g TDS IV
Examples: Peritonitis,
Diverticulitis, Biliary tract
infections
Pancreatitis
Severe acute
necrotising Pancreatitis
Intra-abdominal
infections
Comments
Discuss with Microbiology team as soon as
possible
Severe hypersensitivity
reaction/anaphylaxis to penicillins:
metronidazole + gentamicin
Penicillin allergy (NOT IgE mediated
reaction /anaphylaxis):
Cefuroxime 750mg- 1.5g TDS and
metronidazole 500mg TDS IV+/- gentamicin.
Send 3 sets of blood cultures.
Consider antibiotic therapy if 2 or more
present:
Increased breathlessness
Increased sputum volume
Sputum purulence
If consolidation on CXR treat as CAP.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Seek advice from Microbiology.
Antibiotic
Endocarditis
Condition
Antibiotics may not be required
See “Comments”
Co-amoxiclav oral or IV depending on
severity for 5-7 days. Review need
for IV therapy on a daily basis.
Penicillin allergy : Clarithromycin 500mg BD
daily PO for 5-7 days
Respiratory Tract Acute exacerbation of
Infections
COPD
(no consolidation on CXR)
13
Condition
Antibiotic
Non-severe CDAD:
Metronidazole 400mg TDS PO for 10
days
Severe CDAD:
Early surgical review recommended
Vancomycin 125mg PO QDS
for 10 days
Inability to take oral medications:
Metronidazole 500 mg IV TDS/QDS for 10
days
Consider antibiotics ONLY if
immunosuppressed or signs of
systemic sepsis.
Discuss with microbiology team.
Antibiotic Treatment most often not necessary.
Comments
Refer to HSE SE Clostridium difficile
guidelines in the Infection Control Manual
available on all wards.8
Discontinue other antibiotics if
possible.
Discuss with microbiology team if not
responding to therapy.
Ensure appropriate isolation with standard
and contact precautions are instituted. Send
stool specimen to laboratory. Note all
patients with unexplained diarrhoea
should be isolated.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Clostridium difficile
Associated Disease
(CDAD)
Gastro-intestinal Acute gastroenteritis
Infections
14
Condition
Antibiotic
Comments
At least 2 sets of blood cultures
recommended from each lumen of CVC
and peripheral OR peripheral X 2 if no CVC
is present.
Culture of urine, stool, CSF, skin and
respiratory specimens should be guided by
clinical signs / symptoms but should not
be performed routinely.
Persistent fever after 4 days of
antibiotic therapy: consider adding
empiric antifungal agent.
Consider need for viral testing &/or antiviral
therapy if clinical indication
Consider if patient at risk for infection
due to MRSA , if so, add vancomycin.
Consider other multiresistant organisms.
Check previous laboratory results
Penicillin allergy: Gentamicin, metronidazole
plus teicoplanin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Assess patient re possible focus Ensure blood cultures taken. See individual
of infection –e.g. urinary tract, infection treatment guidelines for appropriate
skin/soft tissue, abdominal, therapy.
chest, neurological., community Initial empirical therapy if no obvious
or hospital acquired, travel
source: Piperacillin-tazobactam 4.5g
history, recent antibiotic
IV TDS. Consider adding gentamicin if
therapy, presence of prosthetic haemodynamically unstable / severe infection.
devices, intravascular catheters, Consider need for additional gram positive
etc.
cover e.g vancomycin(or teicoplanin if patient
is already on gentamicin)
Neutropenic sepsis 9
Initial Empiric therapy: Piperacillintazobactam 4.5g QDS IV. Add gentamicin
if complications (e.g. hypotension, pneumonia
or antimicrobial resistance suspected).
Consider adding vancomycin or teicoplanin
for specific clinical indications e.g. suspected
CVC-related infection or complications as above.
Penicillin allergy (Not IgE mediated
reaction/anaphylaxis): Ceftazidime 2g TDS IV
plus vancomycin or teicoplanin.
Severe IgE mediated reaction/anaphylaxis to
penicillin: Ciprofloxacin plus gentamicin plus
teicoplanin
Septicaemia
15
Refer to surgical team urgently.
Piperacillin-tazobactam 4.5g IV 6 to 8
hourly plus clindamycin 600mg-1.2g
QDS +/- gentamicin. Discuss with
Microbiologist.
Co-amoxiclav 625mg TDS (or 1.2g
TDS IV if severe) for 5 days
Necrotising soft tissue
infections/Necrotising
fascitis
Human and animal bites
Antibiotic
Flucloxacillin 2g QDS IV plus sodium
fusidate 500mg tabs TDS PO (or fusidic
acid susp. 750mg TDS PO)
Penicillin allergy (NOT IgE mediated
reaction/anaphylaxis): Cefuroxime 1.5g TDS
IV plus fusidic acid as above.
Severe IgE mediated reaction/anaphylaxis
to penicillin: Vancomycin plus fusidic acid as
above.
Benzylpenicillin (penicillin G) 1.2g-2.4g
QDS IV plus flucloxacillin 1-2g QDS IV
Penicillin allergy (NOT IgE mediated
reaction/anaphylaxis): Cefuroxime 750mg1.5g TDS
Severe IgE mediated reaction/anaphylaxis
to penicillin: Clindamycin 1.2g QDS IV.
Condition
Osteomyelitis / Septic
arthritis
Comments
Penicillin allergy: Doxycycline 100mg BD PO.
If severe discuss with microbiology team.
NOTE: severe cellulitis should not be
treated with a macrolide
(erythromycin/clarithromycin).
If MRSA suspected use vancomycin.
Switch to flucloxacillin 500mg-1g QDS PO
when clinical improvement achieved. Treat
for 10 days minimum.
Discuss possible oral switch options with the
clinical microbiology team.
MRSA known or high risk: vancomycin.
Adjust treatment when cultures available.
Treat for 4 to 6 weeks. Monitor CRP.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Skin and soft tissue Cellulitis, erysipelas
Infections
Bone and Joint
Infections
16
ENT Infections
Central Nervous
System
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Penicillin allergy: Clarithromycin BD 500mg
PO for 5-7 days
Sinusitis, otitis media Co-amoxiclav 1.2 g IV / 625mg TDS
PO for 5-7 days
Penicillin allergy: Consider clindamycin +
ciprofloxacin for 7-10 days.
Adjust dose in renal impairment.
Request HSV PCR on CSF.
Penicillin allergy: Clarithromycin BD 500mg
PO for 10 days
Ceftriaxone 2g BD IV for 7-10 days
Comments
Seek Microbiology advice.
Consider Dexamethasone phosphate
for bacterial meningitis.(10mg IV 6
hourly for 2 to 4 days. Must commence
before or at same time as antibiotic).
Send Blood cultures, throat swab,
EDTA blood for PCR +/- CSF. Isolate
patient. Notify Public Health.
Tonsillitis/pharyngitis Phenoxymethylpenicillin (penicillin V)
666mg QDS PO for 10 days
Severe: Benzylpenicillin (penicillin G) 1.2g
QDS IV
Acute epiglottitis
Acyclovir 10 mg / kg IV every 8 hours
(use ideal body weight in obese patients)
Encephalitis
Antibiotic
Ceftriaxone 2g BD IV If Listeria risk add
amoxicillin 2g 4 hrly IV. If Strep pneumoniae
(pneumococcus) suspected add vancomycin
until sensitivities confirmed.
Treat for 14 days if pneumococcus. Treat for 7 days
if meningococcus. Severe IgE mediated reaction/
anaphylaxis to penicillin: chloramphenicol 1g IV
QDS. If immunocompromised add vancomycin and
co-trimoxazole.
Condition
Meningitis
17
Infection
Genital Tract
Condition
Antibiotic
Comments
Switch to oral/outpatient regime
when satisfactory response for ≥ 24
hours.
Total duration of therapy: 14 days
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Consider treating partner.
In pregnancy, a macrolide (azithromycin
or erythromycin) may be used instead of
doxycycline.
Note: Fluoroquinolones (eg ciprofloxacin
Severe 1gE mediated reaction/ anaphylaxis
or ofloxacin) not recommended due to
to penicillin: Clindamycin 900 mg IV TDS +
increasing resistance. Ref: MMWR 59 (RRgentamicin (refer pg 19) + doxycycline PO
12)2010 & www.cdc.gov/std/treatment
100 mg BD
Inpatient Rx: Ceftriaxone 1g once daily IV +
doxycycline 100mg BD PO + metronidazole PO
400mg TDS
Pelvic Inflammatory
Outpatient Rx: Ceftriaxone 250mg IM or IV as
Disease (PID), Salpingitis, single dose, then doxycycline PO 100 mg BD +
Tubo-ovarian abscess
metronidazole PO 400mg TDS
18
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Dose Adjustment
Levels
Comments
Endocarditis: 1mg/kg IV 12 hourly.
Serum levels:
pre-dose level <1μg/ml
1 hour post dose level of 3-5μg/ml
(not always necessary).
Normal renal function: twice-weekly
serum monitoring may be sufficient.
Abnormal renal function: dosage should
be adjusted according to creatinine
clearance and daily serum assay
results.
Take pre-dose level before the 3rd
dose.
NB Antibiotic assays are done at 12:00 Noon and 4.00 pm Monday to Friday and
12:00 Noon on Saturdays and Sundays. Samples must reach the laboratory in
Waterford Regional Hospital one hour before these above times.
Suitable for normal renal function,
creatinine clearance >80ml/min. Dose
reduction if <80ml/min, seek advice.
Pre-dose levels are required to monitor for
toxicity
Clotted sample 16-18h after the first dose of
gentamicin should be < 1μg/ml.
If >1μg/ml: Check timing of level, review
dosing schedule, check renal function,
NB: Gentamicin doses in excess of consider alternative therapy and seek advice
if necessary.
400mg IV / day are rarely
See page 19 for dosing algorithm.
required.
Dose should never exceed 500mg If continuing gentamicin and renal function is stable,
repeat level twice weekly. Daily levels may be
IV/Day.
required if renal function is unstable.
See page 19 for dosing algorithim.
Note: 1-hour post dose levels are not
necessary except in endocarditis – please
discuss on an individual basis (see comments).
***Clearly state dose, time of dose and time of blood
sample collection on the request form. ***
Infuse in 100ml of glucose 5% or sodium chloride 0.9% over 30-60 minutes.
Once daily Aminoglycoside protocol:
Gentamicin 5mg/kg IV daily
Adult Single Daily Dosing Algorithm for Gentamicin
(Exclusions: Endocarditis & renal impairment. Caution required in CF patients,
pregnant women & patients with severe burns.)
Is Creatinine Clearance (CrCl) >80ml/min?
CrCl = (140-Age) x Weight(kg) (Use ODW if BMI>30)* x 1.23 (males) or 1.04 (females)
Serun Creatinine(µmol/L)
**If anuric (<500mls/day), treat as CrCl<10ml/min
Yes
No
Give first dose of IV
Gentamicin 5mg/kg*
(based on Actual Body Weight or ODW if obese*).
Record actual time of dose (Ideally 4-6pm)
Dose should not exceed 500mg/day
CrCl(ml/min)
50-80
30-50
10-30
<10
Take blood for serum gentamicin level
16-18 hours after FIRST dose.
Record actual time of sampling.
(4pm dosing = 8-10am level,
6pm dosing = 10am-12noon level)
Yes
Is trough level <1µg/ml
Continue current regimen.
Repeat trough levels and serum
creatinine concentration twice
weekly (if renal function is poor/
deteriorating and/or previous trough
levels are high, then levels need to be
checked more frequently e.g. daily)
*Weight used should be actual body weight (ABW) or
for obese patients (BMI>30), an obese dosing weight
(ODW) must be calculated.
ODW = IBW + 0.4 (ABW - IBW)
Dose should never exceed 500mg.
BMI= Weight (kg)/Height (m)²
IBW (males) Kg= 50 + (0.9 x no. of cm over 152cm)
IBW (females) Kg= 45.5 + (0.9 x no. of cm over 152cm)
1 foot = 30.5com, 1 inch = 2.54cm
Dose
4mg/kg
3mg/kg*
2mg/kg*
1-2mg/kg*
redose
when level
<1µg/ml
No
Check time dose was given and
sample taken. Was level taken at
16-18 hours after dose?
No
Yes
Is trough level
>1(µg/ml) but
<2(µg/ml) and
treatment still
Indicated?
No
Seek advice
from Pharmacy
or Clinical
Microbiology
Yes
Reduce once daily
dose by 1mg/kg*
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
19
20
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Levels
6 mg/kg 12 hourly for 3 doses and May be required in certain circumstances eg.
thereafter once daily. Higher doses,
endocarditis.
10- 12mg/kg, in similar dosing schedule Discuss with Microbiology team.
is indicated in serious infections e.g.
MRSA infections and endocarditis. Such
patients should be discussed with the
clinical microbiology team.
Teicoplanin dosage schedule
Levels
Collect predose level before 4th dose of
vancomycin. Give the dose. Any adjustments
necessary can be made to the 5th dose onwards.
Predose level should be between 1015μg/ml. (In severe/complicated
infection 15-20 μg/ml). If continuing
vancomycin and renal function is stable, repeat
level twice weekly. Daily levels may be required
if renal function is unstable. Note that 1- hour
post dose levels are not necessary.
Clearly state dose, time of dose and time of blood
sample collection on the request form.
At weekends routine assays are carried out at
midday on Saturdays and Sundays.
(refer to dosing algorithm page 21): 1520mg/kg (actual body weight).
In severe/complicated infections a
higher dose +/- loading dose to
achieve pre-dose levels of 1520 μg/ml may be required (see
comments).
Vancomycin Dosage Schedule
Comments
Renal impairment:
If teicoplanin is to be used, the full dose
is given for the first 4 days. Thereafter
extended dosing intervals are required.
Must be administered slowly IV at a
maximum rate of 10mg/min to avoid
reaction such as red man syndrome. In
severe/complicated infections a
loading dose of 25-30mg/kg can be
used to facilitate rapid attainment
of target trough serum vancomycin
concentration.
Complicated Infections:
1. Bacteraemia
2. Endocarditis
3. Osteomyelitis
4. Meningitis
5. Hospital Acquired Infections caused by
Staph aureus
Comments
Glycopeptides: Vancomycin & Teicoplanin
Dosing Algorithm for Vancomycin
Is Creatinine Clearance >60ml/min?
CrCl = (140-Age) x Weight (ODW if BMI>30)* (kg) x 1.23 (male) or 1.04 (female)
Serum Creatinine (µmol/L)
If patient is anuric (output <500mls/day), treat as per CrCl < 20ml/min
Yes
Is the patient seriously ill (signs of severe sepsis)?
Yes
No
Give loading dose 25-30mg/kg
(Actual body weight)
Give loading dose 15mg/kg
(Actual body weight)
No
Prescribe maintenance dose 15mg/kg
BD. (Use Actual body weight)
(Preferably at 10am, and 10pm to
facilitate levels.)
CrCl
Dose
Check 1st level
(ml/min)
40-60
15mg/kg od
Before 3rd dose**
20-40
15mg/kg
Before 2nd dose**
every 36-48 hrs.
<20
15mg/kg
Before 2nd dose.
every 72-96 hrs. Hold dose until
level available
Once daily doses should preferably be given at
10am to facilitate checking of levels
1st level before 4th dose. (Level needs
to be PRE-dose)**
Has patient serious infection such as
endocarditis, osteomyelitis, bloodstream
infecion, meningitis or hospital acquired
pneumonia caused by S. aureus?
No
Yes
Target level is 10-15µg/ml.
Is level 10-15µg/ml?
Target level is 15-20µg/ml.
Is level 15-20µg/ml?
Pre-dose level result
Level Dose
alteration
5-10 Increase
each dose
by 250mg
10-15 Maintain
dosing
regimen
15-20 Reduce
each dose
by 250mg
>20
Omit next
dose and
decrease
each dose
by 500mg
Recheck pre-dose
level
After adjusted dose
given and before
following morning dose**
Twice weekly
providing renal
function is stable**
After adjusted dose
given and before
following morning dose**
After adjusted dose
given and
before following
morning dose**
*Weight used should be actual body weight (ABW) or
for obese patients (BMI>30), an obese dosing weight
(ODW) must be calculated.
ODW = IBW + 0.4 (ABW - IBW)
BMI=Weight (kg)/Height (m)²
IBW (males) Kg= 50 + (0.9 x no. of cm over 152cm)
IBW (females) Kg= 45.5 + (0.9 x no. of cm over 152cm)
1 foot = 30.5com, 1 inch = 2.54cm
**Unless renal
function is
deteriorating or
specifically
advised DOSES
SHOULD NOT
BE HELD WHILST
AWAITING
LEVELS
Seek advice
from Pharmacy
or Clinical
Microbiology if
in doubt
Pre-dose level result
Level Dose
alteration
5-10 Increase
each dose
by 500mg
10-15 Increase
each dose
by 250mg
15-20 Maintain
dosing
regimen
20-25 Reduce
each dose
by 250mg
>25
Omit next
dose and
decrease
each dose
by 500mg
Recheck
pre-dose level
After adjusted
dose given and
before following
morning dose**
After adjusted
dose given and
before following
morning dose**
Twice weekly
providing renal
function is stable**
After adjusted
dose given and
before following
morning dose**
After adjusted
dose given and
before following
morning dose**
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
21
22
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
ORAL
Amoxicillin 500mg 8 hr
Co-amoxiclav 625mg 8 hr
Clindamycin 300mg 6 hr
Clindamycin 450mg 6 hr
Flucloxacillin 500mg -1g 6 hr
30 minutes before food
Clarithromycin 500mg 12 hr
Metronidazole 400mg 8 hr
Ciprofloxacin 500 - 750 mg 12 hr
IV
Benzylpenicillin 1.2 -2.4g 4-6 hr
Amoxicillin 1g 6 hr
Co-amoxiclav 1.2g 8 hr
Clindamycin 600mg 6 hr
Clindamycin 1.2g 6 hr
Flucloxacillin 1 - 2 g 6 hr
Clarithromycin 500mg 12 hr
Metronidazole 500mg 8 hr
Ciprofloxacin 400mg 12 hr
“Note: Oral Antimicrobials are significantly less costly than intravenous“
Examples of choices of switch from IV to oral route
ANTIMICROBIALS WITH GOOD
ORAL BIOAVAILABILITY
*Sanford Guide 2010
** Martindale 33rd edition
***Sanford Guide 2010 and Martindale 33rd edition
Antimicrobial
Ciprofloxacin
Clindamycin
Fusidic Acid
Fluconazole
Levofloxacin
Linezolid
Metronidazole
Oral Bioavailability
70%***
90%*
91%(tablets)*
90%*
98%*
100%*
99%**
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
23
RELATIVE COSTS OF ANTIMICROBIALS*
COST OF ONE WEEK’S SUPPLY OF ANTIMICROBIALS
BASED ON NORMAL ADULT DOSE
(antifungals in bold italics)
€0-€10
Flucloxacillin PO, Metronidazole PO, Ciprofloxacin PO,
Amoxicillin PO, Co-amoxiclav PO, Clarithromycin PO
€10-€40
Levofloxin PO, Amoxicillin IV, Metronidazole IV
Co-amoxiclav IV, Cefuroxime IV, Clindamycin PO,
Fusidic acid PO, Fluconazole PO
€40-€60
Piperacillin-Tazobactam IV, Ciprofloxacin IV, Vancomycin IV
€150-€300
Clarithromycin IV, Levofloxacin IV, Rifampicin IV,
Meropenem IV, Ceftriaxone IV, Fluconazole IV
€300-€500
Acyclovir IV, Clindamycin IV,
€500-€1000 Linezolid PO & IV
€1000-€3000 Teicoplanin IV, Tigecycline IV
>€3000
Anidulafungin IV, Voriconazole IV,
Amphoteracin IV, Caspofungin IV
*Correct at time of publication.
24
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
REFERENCES:
1. Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. SARI
Hospital Antimicrobial Stewardship Working Group. December 2009.
2. Policy on Control and Prevention of Meticillin Resistant Staphylococcus
aureus (MRSA) in Acute Hospitals in the HSE/SE. November 2009.
3. Gupta K et al International Clinical Practice Guideline for the treatment of
acute uncomplicated cystitis and pylenephritis in women. 2010 update by
IDSA and ESCMID. CID 2011; 52: 103-120.
4. Lim WS, Baudouin SV, George RC et al. BTS Guidelines for the
management of community acquired pneumonia in adults: update 2009.
Thorax 2009; 64 Suppl 3: iii1-55.
5. Brito V et al. Healthcare - associated pneumonia is a heterogenous
disease, and all patients do not need the same broad-spectrum antibiotic
therapy as complex nosocomial pneumonia. Current Opinion in Infectious
Diseases 2009; 22: 316-325.
6. Masterton. RG et al. Guidelines for the management of hospital acquired
pneumonia in the UK. JAC 2008; 62: 5-34.
7. James D. Chalmers, Mudher Al-Khairalla, Philip M. Short, Tom C.
Fardon and John H. Winter. Proposed changes to management of
lower respiratory tract infections in response to the Clostridium difficile
epidemic. J Antimicrob Chemother 2010; 65: 608-618.
8. Policy on Prevention and Control of Clostridium difficile – associated
disease In Acute Hospitals HSE/South East. January 2010.
9. Clinical Practice Guideline for the Use of Antimicrobial Agents in
Neutropenic Patients with Cancer, 2010 update by the IDSA. CID 2011;
52(4): e56-e93.
10. Davey et al. Interventions to improve antibiotic prescribing practices for
hospital inpatients (review). The Cochrane Library Oct 2008.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
25
HSE South East Acute Hospital Network Antimicrobial
Stewardship Group Members
Microbiology Department WRH:
Microbiology SpRs
Ext. 2490/8053
Bleep #821 278
Dr. M. Hickey
Ext.
Dr. M. Doyle
Ext. 2621.2097
Dr. B. Carey
Ext.
Ms. C. Troy, Surveillance Scientist
Ext. 2488/2489
}
Pharmacy Departments.:
WRH Antimicrobial Pharmacist
Ext. 2530/2453
WGH Antimicrobial Pharmacist
Ext. 3261
SLKK/Kilcreene Antimicrobial Pharmacist Ext. 5372/5328
STGH Antimicrobial Pharmacist
26
Ext. 7119
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
empiric use of
antimicrobials
in adults
HSE South East Hospital Network
June 2012
Review Date: June 2013
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Acknowledgement: Gentamicin and Vancomycin Algorithims
page 19 & 21 adapted from original algorithims kindly
provided by Beaumont/Connolly Hospital Antimicrobial
Stewardship Committee in 2011.
Issued by:
Dr. M. Hickey & Dr. D. Keady June 2006
Revised by:
Dr. M. Hickey June 2007
Revised by:
Dr. M. Hickey, Dr. M. Doyle &
Dr. B. Carey April 2008
Revised by:
Dr. M. Hickey, Dr. M. Doyle &
Dr. B. Carey June 2009
Revised by:
Dr. M. Hickey & Dr. M. Doyle June 2010
Revised by:
HSE SE Antimicrobial Stewardship Group
June 2011
Revised by:
HSE SE Antimicrobial Stewardship Group
June 2012
Review Date: June 2013
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Table of Contents
Page No.
General Guidance
2-3
Restricted and Reserve Antimicrobials
4
MRSA
5
Urinary Tract Infection
6
Respiratory Tract Infection
7-12
Endocarditis & Intra-abdominal Infections
12
Gastro-intestinal Infection
13
Septicaemia & Neutropenic Sepsis
14
Bone and Joint Infections
15
Skin and Soft tissue Infections
15
Central Nervous System
16
ENT infections
16
Genital Tract Infection
17
Gentamicin
18-19
Glycopeptides: Vancomycin, Teicoplanin
20-21
Switch from IV to PO
Oral Bioavailability and Relative Costs
22
23-24
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
1
2
Where possible indicate intended duration of therapy at point of initial prescribing. Review IV antimicrobial
therapy daily.
Document indication for therapy and intended duration in medical record. Note these guidelines are intended
for empiric therapy. Rationalise when microbiology results become available.
Piperacillin-tazobactam and co-amoxiclav provide good anaerobic cover. Concurrent metronidazole is
NOT required unless there is gross faecal contamination – e.g. faecal peritonitis. Treatment of aspiration
pneumonia does NOT require addition of metronidazole to either of these antibiotics.
Some antibiotics e.g. ciprofloxacin, fusidic acid and metronidazole have excellent oral
bioavailability and the oral route should be used where possible. IV formulations of these should only be
used if the patient is not absorbing or unable to have oral medications.
2.
3.
4.
5.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
NB: The prescriber should always check prescribing information such as cautions,
contraindications, interactions and side effects when considering antimicrobial therapy. Ensure
information on antimicrobial prescribing, including risks and side effects associated with
antimicrobial treatment, is available to patients or their legal guardians.¹
1.
GENERAL GUIDANCE
3
For oral switch guidelines see pg 22. Oral switch is usually to PO formulation of same antibiotic where
available, except IV penicillin to PO amoxicillin as oral absorption of penicillin is very poor.
Penicillin allergy: obtain & document proper history. If IgE mediated allergic reaction (e.g.
anaphylaxis, angioneurotic oedema, immediate urticaria) avoid all beta-lactams. If rash only, a cephalosporin
may be considered. Erythromycin is often NOT a good substitute.
Flucloxacillin and other betalactams such as co-amoxiclav, piperacillin-tazobactam, cephalosporins and
meropenem do not cover MRSA.
Risk of Clostridium difficile associated with all antibiotic use. Particular risk with all fluroquinolones (e.g.
levofloxacin and ciprofloxacin), clindamycin and cephalosporins.
7.
8.
9.
10.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Oral switch – consider when patient is afebrile and infection parameters are settling for 48 hours and normal
oral absorption. Generally NOT appropriate in meningitis, endocarditis, febrile neutropenia or acute
osteomyelitis/septic arthritis.
6.
Restricted/Reserve Antimicrobials:
A Cochrane review has found that reserving access to selected antimicrobials is the most effective
10
component of any Antimicrobial Stewardship Programme.
Below is the list of Restricted and Reserve antimicrobials for the SE Acute Hospital Network.
These antimicrobials should only be prescribed when this is in line with the recommendations of this
guideline or following discussion with the Clinical Microbiologist.
Indication for therapy and any discussions/advice from the Clinical Microbiologist should be
documented accurately in patient’s medical record.
Restrictions are in place which limit access to these Antimicrobials. Please refer to South East Acute
Hospital Network Guidelines for use of Reserve and Restricted Antimicrobials for details.
Restricted Antimicrobials
IV Piperacillin/Tazobactam
IV Ceftriaxone
IV Ciprofloxacin
IV/PO Levofloxacin
IV Chloramphenicol
IV/PO Clindamycin
IV Teicoplanin
IV Vancomycin
IV/PO Linezolid
IV Meropenem
*Reserve Antimicrobials
IV Cefotaxime
IV Ceftazidime
IV Erythromycin
IV Ofloxacin
IV Colistin
IV Daptomycin
IV Tigecycline
Antifungals
Liposomal Amphotericin B
Anidulafungin
Caspofungin
Voriconazole
Posaconazole
* Reserve antimicrobials should only be prescribed when recommended by a
Consultant and following discussion with the Clinical Microbiologist.
4
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
MRSA
(Meticillin Resistant Staphylococcus aureus)
Infection with MRSA should be suspected if:
•
Patient has previously been colonized with MRSA.
(Please check patients notes or check laboratory
enquiry for ‘SIF code’)
•
Recent hospitalization (within 12 months)
•
Transfer from another hospital or long term care
facility.
•
Other situation where increased clinical suspicion
of MRSA (Please refer to Policy on Control and
Prevention of Meticillin Resistant Staphylococcus
aureus (MRSA) in Acute Hospitals in the HSE/SE.
November 2009 for additional information)²
If MRSA infection is suspected, consider
including a glycopeptide (Vancomycin or
Teicoplanin, see page 20) in the empiric treatment
regimen.
MRSA eradication: Please refer to Policy on Control
and Prevention of Meticillin Resistant Staphylococcus
aureus (MRSA) in Acute Hospitals in the HSE/SE.
November 2009.²
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
5
6
Urinary Tract
Infections³
Condition
Antibiotic
Comments
For patients with catheter associated UTIs,
antibiotics are unlikely to resolve the UTI
unless the catheter is removed. If systemic
sepsis suspected treat as per Pyelonephritis.
Piperacillin-tazobactam 4.5g TDS for 1014 days or gentamicin (see page 18 for dosing
regimen).
Ciprofloxacin 500-750mg BD PO for
2-6 weeks.
Catheter associated
UTI
Pyelonephritis
Prostatitis
Relapse common. Follow up advised. Check
antimicrobial sensitivity where possible.
Send blood cultures and MSU. Rationalise
therapy as soon as possible. Check culture
and antimicrobial sensitivity results.
Patients with recurrent UTIs may have
resistant organisms. Use 7-10 days treatment
in males.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Refer to recent culture results.
If septicaemic: as for pyelonephritis
Nitrofurantoin is not appropriate if creatinine
First line: Nitrofurantoin MR 100mg BD PO
clearance is < 50 ml/min.
for 5 days
Second line: Co-Amoxiclav 625mg TDS PO for 3 days In pregnancy nitrofurantoin may also be used
but it should be avoided at term.
Hospital acquired or
recurrent UTI or
complicated UTI
Lower urinary tract
infection (uncomplicated)
7
COMMUNITY ACQUIRED PNEUMONIA
Condition
Antibiotic
Comments
CURB-65 score should be used with caution
in younger patients as it may underestimate
severity in these patients.
Community Acquired Pneumonia:
Assess severity using CURB-65 score as per
BTS guidelines:
Confusion (new onset)
Urea >7mmol/L
RR≥30/min
BP - hypotensive: SBP <90mmHg or DBP
≤60mmHg
Age ≥ 65 years
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Respiratory Tract Community Acquired
Infections
Pneumonia
These guidelines are not aimed at:
(a) Patients with known predisposing conditions such as cancer or immunosuppression admitted
with pneumonia to specialist units such as oncology, haematology, palliative care, infectious
disease units or AIDS units
(b) Adults with non pneumonic LRTI, including illnesses labelled as acute bronchitis, acute
exacerbations of COPD or “chest infections”
Based on “British Thoracic Society guidelines for the management of
4
community acquired pneumonia in adults: Update 2009.”
8
Community
Acquired
Pneumonia
Levofloxacin 500mg PO/IV OD (12
hourly if severe)
Legionellosis
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
IV route to be used if oral absorption
unreliable. Early oral switch where possible.
Microbiology: Send blood cultures,
sputum, urine for pneumococcal antigen.
7 days appropriate antibiotic therapy is
recommended.
Co-amoxiclav 1.2g tds IV plus clarithromycin
Microbiology: Send blood cultures, sputum
500mg bd IV.
(requesting legionella culture), urine for
(If legionella strongly suspected consider adding pneumococcal antigen and legionella antigen,
levofloxacin)
CRP.
Penicillin allergy (NOT IgE mediated reaction
Consider switch to PO antibiotics as soon as
/anaphylaxis): cefuroxime 750mg-1.5g tds
clinical improvement occurs and patient is
IV plus clarithromycin 500mg bd IV.
apyrexial for 24 hours.
Severe IgE mediated reaction/anaphylaxis
7-10 days appropriate antibiotics is
to penicillin: levofloxacin 500mg PO/IV OD
proposed. This may need to be extended to
(12 hourly if severe).
14-21 days according to clinical judgement.
High severity
(CURB65 = 3-5)
15 - 40% mortality
Amoxicillin 500mg-1.0g tds PO plus
clarithromycin 500mg bd PO.
(IV if PO administration not possible.)
Penicillin allergy: PO doxycycline
Comments
No microbiological tests required. 7
days appropriate antibiotic therapy is
recommended.
Moderate Severity
(CURB65 = 2)
9% mortality
Antibiotic
Amoxicillin 500mg tds PO. (IV if PO
administration not possible.)
Penicillin allergy: clarithromycin 500mg BD
or doxycycline 200mg OD PO loading dose
then 100mg OD PO.
Condition
Low severity
(CURB65 = 0-1)
<3% mortality
9
Intravenous co-amoxiclav
and macrolide
Oral amoxicillin
and macrolide
Oral amoxicillin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
CURB-65 score should be used with caution in younger patients as it may underestimate severity in these patients
Inpatient
management
Inpatient
management
Outpatient
management
High risk
3-5 points
Intermediate risk
2 points
Low risk
0 or 1 point
CURB65 score
New onset mental confusion
Urea>7 mmol/L
Respiratory rate ≥ 30/min
Systolic blood pressure <90mmHg and/or
diastolic blood pressure ≤60mmHg
Age ≥65 years
BTS-recommended therapy for Community Acquired Pneumonia
(Taken from J Antimicrob Chemother 2012; 65: page 612) 4
10
Respiratory
Tract
Infections
Comments
If patient is considered to be high risk
for MRSA, consider adding Vancomycin
For confirmed legionellosis see page 8.
Consider legionella risk. In at risk patients
send urine for legionella antigen and add
clarithromycin empirically. Send sputum for
Legionella culture, if possible
Send sputum for culture if possible
If patient is considered to be high risk
for MRSA, consider adding Teicoplanin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Penicillin allergy: if NOT IgE
mediated/anaphylaxis and if pneumonia is not severe
consider cefuroxime 1.5g TDS IV.
Severe IgE mediated reaction/anaphylaxis to
penicillin: Levofloxacin 500mg PO/IV OD (12
hourly if severe).
If risk factors for MDR pathogens see page 11.
More than 4 days since admission :
Piperacillin-tazobactam 4.5g TDS IV
Penicillin allergy (NOT IgE mediated reaction
/anaphylaxis): Cefuroxime 750 mg -1.5g TDS IV.
Severe IgE mediated reaction/anaphylaxis to penicillin:
Levofloxacin 500mg PO / IV OD. (12 hourly if severe).
Within 4 days of admission & no recent antibiotics:
Co-amoxiclav 625mg TDS PO or 1.2g TDS IV
for 8 days.
Hospital acquired
pneumonia 6
Antibiotic
Patients from nursing home/chronic care
nursing facility/recent hospitalisation refer to
algorithm page 11.
Condition
Health care
associated
pneumonia5
≥2 Risks for MDR
Treat for MDR Pathogens
See HAP p.10
0 Risks for MDR
Treat as severe CAP
See CAP p.8
≥1 Risk for MDR
Treat for MDR Pathogens
See HAP p.10
Yes (CURB65 score 3 or >)
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Patients with HCAP should be identified and then divided on the basis of severity of illness to guide initial therapy. Patients in each group are then further divided based on whether
they have risk factors for drug-resistant (MDR) pathogens that include: recent antibiotic therapy in the past 6 months, recent hospitalization in the past 3 months, the presence of immune
suppression, and poor functional status as defined by activities of daily living. CAP, community-acquired pneumonia; HAP, hospital-acquired pneumonia.
*Adapted from Brito V, et al. Current Opinion in Infectious Diseases 2009, 22:316-325
0-1 Risks for MDR
Treat for common
CAP Pathogens
See CAP p.8
No (CURB65 score mild or moderate)
Severe pneumonia (Based on CURB65 score)
Presence of risk factors for multi-drug resistant (MDR) pathogens
(recent antibiotics, recent hospitalization, poor functional status, immune suppression)
AND
Assess severity of illness (Use CURB65 score)
HCAP present: Patient from nursing home/chronic care facility, recent hospitalization
Algorithm for healthcare-associated pneumonia (HCAP) therapy*
11
12
Co-amoxiclav 1.2g TDS IV for 7-10
days.
First line: Co-amoxiclav 1.2g TDS IV
Second line: Piperacillin-tazobactam 4.5g TDS
IV. Consider addition of gentamicin
First line: Piperacillin-tazobactam 4.5g TDS
IV. Consider addition of gentamicin
Second line: Meropenem 1g TDS IV
Examples: Peritonitis,
Diverticulitis, Biliary tract
infections
Pancreatitis
Severe acute
necrotising Pancreatitis
Intra-abdominal
infections
Comments
Discuss with Microbiology team as soon as
possible
Severe hypersensitivity
reaction/anaphylaxis to penicillins:
metronidazole + gentamicin
Penicillin allergy (NOT IgE mediated
reaction /anaphylaxis):
Cefuroxime 750mg- 1.5g TDS and
metronidazole 500mg TDS IV+/- gentamicin.
Send 3 sets of blood cultures.
Consider antibiotic therapy if 2 or more
present:
Increased breathlessness
Increased sputum volume
Sputum purulence
If consolidation on CXR treat as CAP.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Seek advice from Microbiology.
Antibiotic
Endocarditis
Condition
Antibiotics may not be required
See “Comments”
Co-amoxiclav oral or IV depending on
severity for 5-7 days. Review need
for IV therapy on a daily basis.
Penicillin allergy : Clarithromycin 500mg BD
daily PO for 5-7 days
Respiratory Tract Acute exacerbation of
Infections
COPD
(no consolidation on CXR)
13
Condition
Antibiotic
Non-severe CDAD:
Metronidazole 400mg TDS PO for 10
days
Severe CDAD:
Early surgical review recommended
Vancomycin 125mg PO QDS
for 10 days
Inability to take oral medications:
Metronidazole 500 mg IV TDS/QDS for 10
days
Consider antibiotics ONLY if
immunosuppressed or signs of
systemic sepsis.
Discuss with microbiology team.
Antibiotic Treatment most often not necessary.
Comments
Refer to HSE SE Clostridium difficile
guidelines in the Infection Control Manual
available on all wards.8
Discontinue other antibiotics if
possible.
Discuss with microbiology team if not
responding to therapy.
Ensure appropriate isolation with standard
and contact precautions are instituted. Send
stool specimen to laboratory. Note all
patients with unexplained diarrhoea
should be isolated.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Clostridium difficile
Associated Disease
(CDAD)
Gastro-intestinal Acute gastroenteritis
Infections
14
Condition
Antibiotic
Comments
At least 2 sets of blood cultures
recommended from each lumen of CVC
and peripheral OR peripheral X 2 if no CVC
is present.
Culture of urine, stool, CSF, skin and
respiratory specimens should be guided by
clinical signs / symptoms but should not
be performed routinely.
Persistent fever after 4 days of
antibiotic therapy: consider adding
empiric antifungal agent.
Consider need for viral testing &/or antiviral
therapy if clinical indication
Consider if patient at risk for infection
due to MRSA , if so, add vancomycin.
Consider other multiresistant organisms.
Check previous laboratory results
Penicillin allergy: Gentamicin, metronidazole
plus teicoplanin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Assess patient re possible focus Ensure blood cultures taken. See individual
of infection –e.g. urinary tract, infection treatment guidelines for appropriate
skin/soft tissue, abdominal, therapy.
chest, neurological., community Initial empirical therapy if no obvious
or hospital acquired, travel
source: Piperacillin-tazobactam 4.5g
history, recent antibiotic
IV TDS. Consider adding gentamicin if
therapy, presence of prosthetic haemodynamically unstable / severe infection.
devices, intravascular catheters, Consider need for additional gram positive
etc.
cover e.g vancomycin(or teicoplanin if patient
is already on gentamicin)
Neutropenic sepsis 9
Initial Empiric therapy: Piperacillintazobactam 4.5g QDS IV. Add gentamicin
if complications (e.g. hypotension, pneumonia
or antimicrobial resistance suspected).
Consider adding vancomycin or teicoplanin
for specific clinical indications e.g. suspected
CVC-related infection or complications as above.
Penicillin allergy (Not IgE mediated
reaction/anaphylaxis): Ceftazidime 2g TDS IV
plus vancomycin or teicoplanin.
Severe IgE mediated reaction/anaphylaxis to
penicillin: Ciprofloxacin plus gentamicin plus
teicoplanin
Septicaemia
15
Refer to surgical team urgently.
Piperacillin-tazobactam 4.5g IV 6 to 8
hourly plus clindamycin 600mg-1.2g
QDS +/- gentamicin. Discuss with
Microbiologist.
Co-amoxiclav 625mg TDS (or 1.2g
TDS IV if severe) for 5 days
Necrotising soft tissue
infections/Necrotising
fascitis
Human and animal bites
Antibiotic
Flucloxacillin 2g QDS IV plus sodium
fusidate 500mg tabs TDS PO (or fusidic
acid susp. 750mg TDS PO)
Penicillin allergy (NOT IgE mediated
reaction/anaphylaxis): Cefuroxime 1.5g TDS
IV plus fusidic acid as above.
Severe IgE mediated reaction/anaphylaxis
to penicillin: Vancomycin plus fusidic acid as
above.
Benzylpenicillin (penicillin G) 1.2g-2.4g
QDS IV plus flucloxacillin 1-2g QDS IV
Penicillin allergy (NOT IgE mediated
reaction/anaphylaxis): Cefuroxime 750mg1.5g TDS
Severe IgE mediated reaction/anaphylaxis
to penicillin: Clindamycin 1.2g QDS IV.
Condition
Osteomyelitis / Septic
arthritis
Comments
Penicillin allergy: Doxycycline 100mg BD PO.
If severe discuss with microbiology team.
NOTE: severe cellulitis should not be
treated with a macrolide
(erythromycin/clarithromycin).
If MRSA suspected use vancomycin.
Switch to flucloxacillin 500mg-1g QDS PO
when clinical improvement achieved. Treat
for 10 days minimum.
Discuss possible oral switch options with the
clinical microbiology team.
MRSA known or high risk: vancomycin.
Adjust treatment when cultures available.
Treat for 4 to 6 weeks. Monitor CRP.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Skin and soft tissue Cellulitis, erysipelas
Infections
Bone and Joint
Infections
16
ENT Infections
Central Nervous
System
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Penicillin allergy: Clarithromycin BD 500mg
PO for 5-7 days
Sinusitis, otitis media Co-amoxiclav 1.2 g IV / 625mg TDS
PO for 5-7 days
Penicillin allergy: Consider clindamycin +
ciprofloxacin for 7-10 days.
Adjust dose in renal impairment.
Request HSV PCR on CSF.
Penicillin allergy: Clarithromycin BD 500mg
PO for 10 days
Ceftriaxone 2g BD IV for 7-10 days
Comments
Seek Microbiology advice.
Consider Dexamethasone phosphate
for bacterial meningitis.(10mg IV 6
hourly for 2 to 4 days. Must commence
before or at same time as antibiotic).
Send Blood cultures, throat swab,
EDTA blood for PCR +/- CSF. Isolate
patient. Notify Public Health.
Tonsillitis/pharyngitis Phenoxymethylpenicillin (penicillin V)
666mg QDS PO for 10 days
Severe: Benzylpenicillin (penicillin G) 1.2g
QDS IV
Acute epiglottitis
Acyclovir 10 mg / kg IV every 8 hours
(use ideal body weight in obese patients)
Encephalitis
Antibiotic
Ceftriaxone 2g BD IV If Listeria risk add
amoxicillin 2g 4 hrly IV. If Strep pneumoniae
(pneumococcus) suspected add vancomycin
until sensitivities confirmed.
Treat for 14 days if pneumococcus. Treat for 7 days
if meningococcus. Severe IgE mediated reaction/
anaphylaxis to penicillin: chloramphenicol 1g IV
QDS. If immunocompromised add vancomycin and
co-trimoxazole.
Condition
Meningitis
17
Infection
Genital Tract
Condition
Antibiotic
Comments
Switch to oral/outpatient regime
when satisfactory response for ≥ 24
hours.
Total duration of therapy: 14 days
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Consider treating partner.
In pregnancy, a macrolide (azithromycin
or erythromycin) may be used instead of
doxycycline.
Note: Fluoroquinolones (eg ciprofloxacin
Severe 1gE mediated reaction/ anaphylaxis
or ofloxacin) not recommended due to
to penicillin: Clindamycin 900 mg IV TDS +
increasing resistance. Ref: MMWR 59 (RRgentamicin (refer pg 19) + doxycycline PO
12)2010 & www.cdc.gov/std/treatment
100 mg BD
Inpatient Rx: Ceftriaxone 1g once daily IV +
doxycycline 100mg BD PO + metronidazole PO
400mg TDS
Pelvic Inflammatory
Outpatient Rx: Ceftriaxone 250mg IM or IV as
Disease (PID), Salpingitis, single dose, then doxycycline PO 100 mg BD +
Tubo-ovarian abscess
metronidazole PO 400mg TDS
18
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Dose Adjustment
Levels
Comments
Endocarditis: 1mg/kg IV 12 hourly.
Serum levels:
pre-dose level <1μg/ml
1 hour post dose level of 3-5μg/ml
(not always necessary).
Normal renal function: twice-weekly
serum monitoring may be sufficient.
Abnormal renal function: dosage should
be adjusted according to creatinine
clearance and daily serum assay
results.
Take pre-dose level before the 3rd
dose.
NB Antibiotic assays are done at 12:00 Noon and 4.00 pm Monday to Friday and
12:00 Noon on Saturdays and Sundays. Samples must reach the laboratory in
Waterford Regional Hospital one hour before these above times.
Suitable for normal renal function,
creatinine clearance >80ml/min. Dose
reduction if <80ml/min, seek advice.
Pre-dose levels are required to monitor for
toxicity
Clotted sample 16-18h after the first dose of
gentamicin should be < 1μg/ml.
If >1μg/ml: Check timing of level, review
dosing schedule, check renal function,
NB: Gentamicin doses in excess of consider alternative therapy and seek advice
if necessary.
400mg IV / day are rarely
See page 19 for dosing algorithm.
required.
Dose should never exceed 500mg If continuing gentamicin and renal function is stable,
repeat level twice weekly. Daily levels may be
IV/Day.
required if renal function is unstable.
See page 19 for dosing algorithim.
Note: 1-hour post dose levels are not
necessary except in endocarditis – please
discuss on an individual basis (see comments).
***Clearly state dose, time of dose and time of blood
sample collection on the request form. ***
Infuse in 100ml of glucose 5% or sodium chloride 0.9% over 30-60 minutes.
Once daily Aminoglycoside protocol:
Gentamicin 5mg/kg IV daily
Adult Single Daily Dosing Algorithm for Gentamicin
(Exclusions: Endocarditis & renal impairment. Caution required in CF patients,
pregnant women & patients with severe burns.)
Is Creatinine Clearance (CrCl) >80ml/min?
CrCl = (140-Age) x Weight(kg) (Use ODW if BMI>30)* x 1.23 (males) or 1.04 (females)
Serun Creatinine(µmol/L)
**If anuric (<500mls/day), treat as CrCl<10ml/min
Yes
No
Give first dose of IV
Gentamicin 5mg/kg*
(based on Actual Body Weight or ODW if obese*).
Record actual time of dose (Ideally 4-6pm)
Dose should not exceed 500mg/day
CrCl(ml/min)
50-80
30-50
10-30
<10
Take blood for serum gentamicin level
16-18 hours after FIRST dose.
Record actual time of sampling.
(4pm dosing = 8-10am level,
6pm dosing = 10am-12noon level)
Yes
Is trough level <1µg/ml
Continue current regimen.
Repeat trough levels and serum
creatinine concentration twice
weekly (if renal function is poor/
deteriorating and/or previous trough
levels are high, then levels need to be
checked more frequently e.g. daily)
*Weight used should be actual body weight (ABW) or
for obese patients (BMI>30), an obese dosing weight
(ODW) must be calculated.
ODW = IBW + 0.4 (ABW - IBW)
Dose should never exceed 500mg.
BMI= Weight (kg)/Height (m)²
IBW (males) Kg= 50 + (0.9 x no. of cm over 152cm)
IBW (females) Kg= 45.5 + (0.9 x no. of cm over 152cm)
1 foot = 30.5com, 1 inch = 2.54cm
Dose
4mg/kg
3mg/kg*
2mg/kg*
1-2mg/kg*
redose
when level
<1µg/ml
No
Check time dose was given and
sample taken. Was level taken at
16-18 hours after dose?
No
Yes
Is trough level
>1(µg/ml) but
<2(µg/ml) and
treatment still
Indicated?
No
Seek advice
from Pharmacy
or Clinical
Microbiology
Yes
Reduce once daily
dose by 1mg/kg*
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
19
20
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Levels
6 mg/kg 12 hourly for 3 doses and May be required in certain circumstances eg.
thereafter once daily. Higher doses,
endocarditis.
10- 12mg/kg, in similar dosing schedule Discuss with Microbiology team.
is indicated in serious infections e.g.
MRSA infections and endocarditis. Such
patients should be discussed with the
clinical microbiology team.
Teicoplanin dosage schedule
Levels
Collect predose level before 4th dose of
vancomycin. Give the dose. Any adjustments
necessary can be made to the 5th dose onwards.
Predose level should be between 1015μg/ml. (In severe/complicated
infection 15-20 μg/ml). If continuing
vancomycin and renal function is stable, repeat
level twice weekly. Daily levels may be required
if renal function is unstable. Note that 1- hour
post dose levels are not necessary.
Clearly state dose, time of dose and time of blood
sample collection on the request form.
At weekends routine assays are carried out at
midday on Saturdays and Sundays.
(refer to dosing algorithm page 21): 1520mg/kg (actual body weight).
In severe/complicated infections a
higher dose +/- loading dose to
achieve pre-dose levels of 1520 μg/ml may be required (see
comments).
Vancomycin Dosage Schedule
Comments
Renal impairment:
If teicoplanin is to be used, the full dose
is given for the first 4 days. Thereafter
extended dosing intervals are required.
Must be administered slowly IV at a
maximum rate of 10mg/min to avoid
reaction such as red man syndrome. In
severe/complicated infections a
loading dose of 25-30mg/kg can be
used to facilitate rapid attainment
of target trough serum vancomycin
concentration.
Complicated Infections:
1. Bacteraemia
2. Endocarditis
3. Osteomyelitis
4. Meningitis
5. Hospital Acquired Infections caused by
Staph aureus
Comments
Glycopeptides: Vancomycin & Teicoplanin
Dosing Algorithm for Vancomycin
Is Creatinine Clearance >60ml/min?
CrCl = (140-Age) x Weight (ODW if BMI>30)* (kg) x 1.23 (male) or 1.04 (female)
Serum Creatinine (µmol/L)
If patient is anuric (output <500mls/day), treat as per CrCl < 20ml/min
Yes
Is the patient seriously ill (signs of severe sepsis)?
Yes
No
Give loading dose 25-30mg/kg
(Actual body weight)
Give loading dose 15mg/kg
(Actual body weight)
No
Prescribe maintenance dose 15mg/kg
BD. (Use Actual body weight)
(Preferably at 10am, and 10pm to
facilitate levels.)
CrCl
Dose
Check 1st level
(ml/min)
40-60
15mg/kg od
Before 3rd dose**
20-40
15mg/kg
Before 2nd dose**
every 36-48 hrs.
<20
15mg/kg
Before 2nd dose.
every 72-96 hrs. Hold dose until
level available
Once daily doses should preferably be given at
10am to facilitate checking of levels
1st level before 4th dose. (Level needs
to be PRE-dose)**
Has patient serious infection such as
endocarditis, osteomyelitis, bloodstream
infecion, meningitis or hospital acquired
pneumonia caused by S. aureus?
No
Yes
Target level is 10-15µg/ml.
Is level 10-15µg/ml?
Target level is 15-20µg/ml.
Is level 15-20µg/ml?
Pre-dose level result
Level Dose
alteration
5-10 Increase
each dose
by 250mg
10-15 Maintain
dosing
regimen
15-20 Reduce
each dose
by 250mg
>20
Omit next
dose and
decrease
each dose
by 500mg
Recheck pre-dose
level
After adjusted dose
given and before
following morning dose**
Twice weekly
providing renal
function is stable**
After adjusted dose
given and before
following morning dose**
After adjusted dose
given and
before following
morning dose**
*Weight used should be actual body weight (ABW) or
for obese patients (BMI>30), an obese dosing weight
(ODW) must be calculated.
ODW = IBW + 0.4 (ABW - IBW)
BMI=Weight (kg)/Height (m)²
IBW (males) Kg= 50 + (0.9 x no. of cm over 152cm)
IBW (females) Kg= 45.5 + (0.9 x no. of cm over 152cm)
1 foot = 30.5com, 1 inch = 2.54cm
**Unless renal
function is
deteriorating or
specifically
advised DOSES
SHOULD NOT
BE HELD WHILST
AWAITING
LEVELS
Seek advice
from Pharmacy
or Clinical
Microbiology if
in doubt
Pre-dose level result
Level Dose
alteration
5-10 Increase
each dose
by 500mg
10-15 Increase
each dose
by 250mg
15-20 Maintain
dosing
regimen
20-25 Reduce
each dose
by 250mg
>25
Omit next
dose and
decrease
each dose
by 500mg
Recheck
pre-dose level
After adjusted
dose given and
before following
morning dose**
After adjusted
dose given and
before following
morning dose**
Twice weekly
providing renal
function is stable**
After adjusted
dose given and
before following
morning dose**
After adjusted
dose given and
before following
morning dose**
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
21
22
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
ORAL
Amoxicillin 500mg 8 hr
Co-amoxiclav 625mg 8 hr
Clindamycin 300mg 6 hr
Clindamycin 450mg 6 hr
Flucloxacillin 500mg -1g 6 hr
30 minutes before food
Clarithromycin 500mg 12 hr
Metronidazole 400mg 8 hr
Ciprofloxacin 500 - 750 mg 12 hr
IV
Benzylpenicillin 1.2 -2.4g 4-6 hr
Amoxicillin 1g 6 hr
Co-amoxiclav 1.2g 8 hr
Clindamycin 600mg 6 hr
Clindamycin 1.2g 6 hr
Flucloxacillin 1 - 2 g 6 hr
Clarithromycin 500mg 12 hr
Metronidazole 500mg 8 hr
Ciprofloxacin 400mg 12 hr
“Note: Oral Antimicrobials are significantly less costly than intravenous“
Examples of choices of switch from IV to oral route
ANTIMICROBIALS WITH GOOD
ORAL BIOAVAILABILITY
*Sanford Guide 2010
** Martindale 33rd edition
***Sanford Guide 2010 and Martindale 33rd edition
Antimicrobial
Ciprofloxacin
Clindamycin
Fusidic Acid
Fluconazole
Levofloxacin
Linezolid
Metronidazole
Oral Bioavailability
70%***
90%*
91%(tablets)*
90%*
98%*
100%*
99%**
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
23
RELATIVE COSTS OF ANTIMICROBIALS*
COST OF ONE WEEK’S SUPPLY OF ANTIMICROBIALS
BASED ON NORMAL ADULT DOSE
(antifungals in bold italics)
€0-€10
Flucloxacillin PO, Metronidazole PO, Ciprofloxacin PO,
Amoxicillin PO, Co-amoxiclav PO, Clarithromycin PO
€10-€40
Levofloxin PO, Amoxicillin IV, Metronidazole IV
Co-amoxiclav IV, Cefuroxime IV, Clindamycin PO,
Fusidic acid PO, Fluconazole PO
€40-€60
Piperacillin-Tazobactam IV, Ciprofloxacin IV, Vancomycin IV
€150-€300
Clarithromycin IV, Levofloxacin IV, Rifampicin IV,
Meropenem IV, Ceftriaxone IV, Fluconazole IV
€300-€500
Acyclovir IV, Clindamycin IV,
€500-€1000 Linezolid PO & IV
€1000-€3000 Teicoplanin IV, Tigecycline IV
>€3000
Anidulafungin IV, Voriconazole IV,
Amphoteracin IV, Caspofungin IV
*Correct at time of publication.
24
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
REFERENCES:
1. Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. SARI
Hospital Antimicrobial Stewardship Working Group. December 2009.
2. Policy on Control and Prevention of Meticillin Resistant Staphylococcus
aureus (MRSA) in Acute Hospitals in the HSE/SE. November 2009.
3. Gupta K et al International Clinical Practice Guideline for the treatment of
acute uncomplicated cystitis and pylenephritis in women. 2010 update by
IDSA and ESCMID. CID 2011; 52: 103-120.
4. Lim WS, Baudouin SV, George RC et al. BTS Guidelines for the
management of community acquired pneumonia in adults: update 2009.
Thorax 2009; 64 Suppl 3: iii1-55.
5. Brito V et al. Healthcare - associated pneumonia is a heterogenous
disease, and all patients do not need the same broad-spectrum antibiotic
therapy as complex nosocomial pneumonia. Current Opinion in Infectious
Diseases 2009; 22: 316-325.
6. Masterton. RG et al. Guidelines for the management of hospital acquired
pneumonia in the UK. JAC 2008; 62: 5-34.
7. James D. Chalmers, Mudher Al-Khairalla, Philip M. Short, Tom C.
Fardon and John H. Winter. Proposed changes to management of
lower respiratory tract infections in response to the Clostridium difficile
epidemic. J Antimicrob Chemother 2010; 65: 608-618.
8. Policy on Prevention and Control of Clostridium difficile – associated
disease In Acute Hospitals HSE/South East. January 2010.
9. Clinical Practice Guideline for the Use of Antimicrobial Agents in
Neutropenic Patients with Cancer, 2010 update by the IDSA. CID 2011;
52(4): e56-e93.
10. Davey et al. Interventions to improve antibiotic prescribing practices for
hospital inpatients (review). The Cochrane Library Oct 2008.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
25
HSE South East Acute Hospital Network Antimicrobial
Stewardship Group Members
Microbiology Department WRH:
Microbiology SpRs
Ext. 2490/8053
Bleep #821 278
Dr. M. Hickey
Ext.
Dr. M. Doyle
Ext. 2621.2097
Dr. B. Carey
Ext.
Ms. C. Troy, Surveillance Scientist
Ext. 2488/2489
}
Pharmacy Departments.:
WRH Antimicrobial Pharmacist
Ext. 2530/2453
WGH Antimicrobial Pharmacist
Ext. 3261
SLKK/Kilcreene Antimicrobial Pharmacist Ext. 5372/5328
STGH Antimicrobial Pharmacist
26
Ext. 7119
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
