hse se antibiotic guidelines 2012 booklet
Post on 18-Jul-2016
230 Views
Preview:
DESCRIPTION
TRANSCRIPT
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 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index 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 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6 1
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 22
Oral Bioavailability and Relative Costs 23-24
2
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
GEN
ERA
L G
UID
AN
CE
1.
NB: T
he p
resc
riber
shou
ld a
lway
s che
ck p
resc
ribing
info
rmat
ion
such
as c
autio
ns,
cont
raind
icatio
ns, i
nter
actio
ns a
nd si
de e
ffects
whe
n co
nsid
ering
ant
imicr
obia
l the
rapy
. Ens
ure
infor
mat
ion
on a
ntim
icrob
ial p
resc
ribing
, inc
luding
risk
s and
side
effe
cts a
ssoc
iate
d w
ith
antim
icrob
ial t
reat
men
t, is
avai
labl
e to
pat
ients
or t
heir
legal
gua
rdia
ns.¹
2.
Wher
e pos
sible
indica
te int
ende
d dur
ation
of th
erap
y at p
oint o
f init
ial pr
escri
bing.
Revie
w IV
antim
icrob
ial
ther
apy d
aily.
3.
Docu
ment
indic
ation
for t
hera
py an
d int
ende
d dur
ation
in m
edica
l rec
ord.
Note
thes
e guid
eline
s are
inten
ded
for e
mpiri
c the
rapy
. Rati
onali
se w
hen m
icrob
iolog
y res
ults b
ecom
e ava
ilable
.
4.
Piper
acilli
n-taz
obac
tam an
d co-
amox
iclav
prov
ide g
ood
anae
robi
c cov
er. C
oncu
rrent
metr
onida
zole
is NO
T req
uired
unles
s the
re is
gros
s fae
cal c
ontam
inatio
n – e.
g. fa
ecal
perit
onitis
. Tre
atmen
t of a
spira
tion
pneu
monia
does
NOT
requ
ire ad
dition
of m
etron
idazo
le to
eithe
r of t
hese
antib
iotics
.
5.
Some
antib
iotics
e.g.
cipro
floxa
cin, f
usid
ic ac
id an
d met
ronid
azol
e hav
e exc
ellen
t ora
l bi
oava
ilabi
lity
and t
he or
al ro
ute s
hould
be us
ed w
here
possi
ble. I
V for
mulat
ions o
f the
se sh
ould
only
be
used
if th
e pati
ent is
not a
bsor
bing
or u
nabl
e to
hav
e or
al m
edica
tions
.
3
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
6.
Oral
switc
h – co
nside
r whe
n pati
ent is
afeb
rile a
nd in
fecti
on pa
rame
ters a
re se
ttling
for 4
8 ho
urs a
nd no
rmal
oral
abso
rptio
n. Ge
nera
lly N
OT ap
prop
riate
in m
ening
itis,
endo
card
itis,
febr
ile n
eutro
penia
or ac
ute
oste
omye
litis/
sept
ic ar
thrit
is.
7.
For o
ral s
witch
guide
lines
see p
g 22.
Ora
l swi
tch is
usua
lly to
PO fo
rmula
tion o
f sam
e ant
ibioti
c whe
re
avail
able,
exce
pt IV
pen
icillin
to P
O am
oxici
llin as
oral
abso
rptio
n of p
enici
llin is
very
poor.
8.
Penic
illin
aller
gy: o
btai
n &
docu
men
t pro
per h
istor
y. If
IgE m
ediat
ed al
lergic
reac
tion (
e.g.
anap
hylax
is, an
gione
uroti
c oed
ema,
imme
diate
urtic
aria)
avoid
all b
eta-la
ctams
. If r
ash o
nly, a
ceph
alosp
orin
may b
e con
sider
ed. E
ryth
romy
cin is
often
NOT
a go
od su
bstit
ute.
9.
Fluclo
xacil
lin an
d oth
er be
talac
tams s
uch a
s co-
amox
iclav
, pipe
racil
lin-ta
zoba
ctam,
ceph
alosp
orins
and
mero
pene
m do
not
cove
r MRS
A.
10.
Risk o
f Clos
tridiu
m dif
ficile
asso
ciated
with
all a
ntibi
otic u
se. P
artic
ular r
isk w
ith al
l flur
oquin
olone
s (e.g
. lev
oflox
acin
and c
iprofl
oxac
in), c
linda
mycin
and c
epha
lospo
rins.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 64
Restricted/Reserve Antimicrobials: A Cochrane review has found that reserving access to selected antimicrobials is the most effective component of any Antimicrobial Stewardship Programme.10
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 *Reserve Antimicrobials IV Piperacillin/Tazobactam IV Cefotaxime IV Ceftriaxone IV Ceftazidime IV Ciprofloxacin IV Erythromycin IV/PO Levofloxacin IV OfloxacinIV Chloramphenicol IV ColistinIV/PO Clindamycin IV DaptomycinIV Teicoplanin IV TigecyclineIV Vancomycin AntifungalsIV/PO Linezolid Liposomal Amphotericin BIV Meropenem Anidulafungin Caspofungin Voriconazole Posaconazole
* Reserve antimicrobials should only be prescribed when recommended by a Consultant and following discussion with the Clinical Microbiologist.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6 5
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
6
Urina
ry Tr
act
Infe
ction
s³Lo
wer
urin
ary
tract
infec
tion
(unc
ompli
cated
)
Hosp
ital a
cquir
ed o
rre
curre
nt U
TI o
rco
mpl
icate
d UT
I
Cath
eter
ass
ocia
ted
UTI
Pyelo
neph
ritis
Pros
tatit
is
First
line:
Nitro
fura
ntoi
n M
R 10
0mg
BD P
O fo
r 5 d
ays
Seco
nd lin
e: Co
-Amo
xiclav
625
mg TD
S PO
for 3
days
Refe
r to r
ecen
t cult
ure r
esult
s.If
septi
caem
ic: as
for p
yelon
ephr
itis
For p
atien
ts wi
th ca
thete
r asso
ciated
UTIs
,an
tibiot
ics ar
e unli
kely
to re
solve
the U
TIun
less t
he ca
thete
r is r
emov
ed. I
f sys
temic
seps
is su
spec
ted tr
eat a
s per
Pyelo
neph
ritis.
Pipe
racil
lin-ta
zoba
ctam
4.5
g TD
S fo
r 10-
14 d
ays o
r gen
tamici
n (se
e pag
e 18
for d
osing
regim
en).
Cipr
oflox
acin
500-
750m
g BD
PO
for
2-6
wee
ks.
Nitro
fura
ntoin
is no
t app
ropr
iate i
f cre
atinin
ecle
aran
ce is
< 5
0 ml
/min.
In pr
egna
ncy n
itrof
uran
toin m
ay al
so be
used
bu
t it sh
ould
be av
oided
at te
rm.
Patie
nts w
ith re
curre
nt U
TIs m
ay ha
vere
sistan
t org
anism
s. Us
e 7-1
0 da
ys tr
eatm
ent
in ma
les.
Send
bloo
d cult
ures
and M
SU. R
ation
alise
ther
apy a
s soo
n as p
ossib
le. Ch
eck c
ultur
e an
d ant
imicr
obial
sens
itivity
resu
lts.
Relap
se co
mmon
. Foll
ow up
advis
ed. C
heck
antim
icrob
ial se
nsitiv
ity w
here
possi
ble.
Co
nditi
on
Antib
iotic
Co
mm
ents
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
7
CO
MM
UN
ITY
ACQ
UIR
ED P
NEU
MO
NIA
Base
d o
n “
Bri
tish
Thora
cic
Soci
ety g
uid
elin
es f
or
the
managem
ent
of
com
munity a
cquir
ed p
neu
monia
in a
dults:
Update
2009.”
4
Thes
e gu
idel
ines
are
not
aim
ed a
t: (a
) Pat
ient
s w
ith k
now
n pr
edis
posi
ng c
ondi
tions
suc
h as
can
cer
or im
mun
osup
pres
sion
adm
itted
w
ith p
neum
onia
to s
peci
alis
t uni
ts su
ch a
s on
colo
gy, h
aem
atol
ogy,
pal
liativ
e ca
re, i
nfec
tious
di
seas
e un
its o
r A
IDS
units
(b
) Adu
lts w
ith n
on p
neum
onic
LRT
I, in
clud
ing
illne
sses
labe
lled
as a
cute
bro
nchi
tis, a
cute
ex
acer
batio
ns o
f CO
PD o
r “c
hest
infe
ctio
ns”
Co
nditi
on
Antib
iotic
Co
mm
ents
Resp
irato
ry Tr
act
Infe
ction
sCo
mm
unity
Acq
uired
Pneu
mon
iaCo
mm
unity
Acq
uired
Pne
umon
ia:
Asse
ss se
verit
y usin
g CUR
B-65
scor
e as p
er
BTS g
uideli
nes:
Conf
usion
(new
onse
t)Ur
ea >
7mmo
l/LRR≥3
0/mi
nBP
- hy
poten
sive:
SBP <
90mm
Hg or
DBP
≤60m
mHg
Age ≥
65
year
s
CURB
-65
score
shou
ld be
used
with
caut
ion
in yo
unge
r pati
ents
as it
may u
nder
estim
ate
seve
rity i
n the
se pa
tient
s.
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
8
Co
nditi
on
Antib
iotic
Co
mm
ents
Com
mun
ity
Acqu
ired
Pneu
mon
ia
Low
seve
rity
(CUR
B65
= 0-
1)<3
% mo
rtality
Mod
erat
e Se
verit
y(C
URB6
5 =
2)9%
mor
tality
High
seve
rity
(CUR
B65
= 3-
5)15
- 40
% mo
rtality
Legio
nello
sis
Amox
icillin
500
mg
tds P
O. (I
V if
PO
adm
inist
ratio
n no
t pos
sible.
)Pe
nicilli
n alle
rgy:
clarit
hrom
ycin
500m
g BD
or do
xycy
cline
200
mg O
D PO
load
ing do
seth
en 1
00mg
OD
PO.
Amox
icillin
500
mg-
1.0g
tds P
O pl
us
clarit
hrom
ycin
500m
g bd
PO.
(IV if
PO
adm
inist
ratio
n no
t pos
sible.
)Pe
nicilli
n alle
rgy:
PO do
xycy
cline
Co-a
mox
iclav
1.2
g td
s IV
plus
clar
ithro
myc
in 50
0mg
bd IV
.(If
legi
onell
a st
rong
ly su
spec
ted
cons
ider
add
ing
levofl
oxac
in)Pe
nicilli
n alle
rgy (
NOT I
gE m
ediat
ed re
actio
n/a
naph
ylaxis
): ce
furo
xime 7
50mg
-1.5
g tds
IV pl
us cl
arith
romy
cin 5
00mg
bd IV
.Se
vere
IgE m
ediat
ed re
actio
n/an
aphy
laxis
to pe
nicilli
n: lev
oflox
acin
500m
g PO/
IV O
D(1
2 ho
urly
if se
vere
).
Levo
floxa
cin 5
00m
g PO
/IV
OD (1
2ho
urly
if se
vere
)
No m
icrob
iolog
ical te
sts re
quire
d. 7
days
appr
opria
te an
tibiot
ic th
erap
y is
reco
mmen
ded.
Micro
biolog
y: Se
nd bl
ood c
ultur
es,
sput
um, u
rine f
or pn
eumo
cocca
l ant
igen.
7 da
ys ap
prop
riate
antib
iotic
ther
apy i
s re
comm
ende
d. Mi
crobio
logy:
Send
bloo
d cult
ures
, spu
tum
(requ
estin
g leg
ionell
a cult
ure)
, urin
e for
pn
eumo
cocca
l ant
igen a
nd le
gione
lla an
tigen
, CR
P.Co
nside
r swi
tch to
PO an
tibiot
ics as
soon
as
clinic
al im
prov
emen
t occu
rs an
d pati
ent is
ap
yrex
ial fo
r 24
hour
s.7-
10 d
ays a
ppro
priat
e ant
ibioti
cs is
prop
osed
. This
may
need
to be
exten
ded t
o 14
-21
days
acco
rding
to cl
inica
l judg
emen
t.
IV ro
ute t
o be u
sed i
f ora
l abs
orpti
on
unre
liable
. Ear
ly or
al sw
itch w
here
possi
ble.
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
9
CURB6
5 s
core
New
ons
et m
enta
l con
fusi
onU
rea>
7 m
mol
/LRe
spira
tory
rat
e ≥
30/m
inSy
stolic
blo
od p
ress
ure
<90m
mH
g an
d/or
dias
tolic
blo
od p
ress
ure ≤6
0mm
Hg
Age
≥65
yea
rs
Low
ris
k0
or 1
poi
ntIn
term
edia
te r
isk
2 po
ints
Hig
h ris
k3-
5 po
ints
Inpa
tient
man
agem
ent
Inpa
tient
man
agem
ent
Ora
l am
oxic
illin
and
mac
rolid
eIn
trave
nous
co-
amox
icla
van
d m
acro
lide
Out
patie
ntm
anag
emen
t
Ora
l am
oxic
illin
BTS
-rec
om
men
ded
ther
apy f
or
Com
munity A
cquir
ed P
neu
monia
(Tak
en fr
om J
Ant
imic
rob
Che
mot
her
2012
; 65:
pag
e 61
2) 4
CU
RB-6
5 sc
ore
shou
ld b
e us
ed w
ith c
autio
n in
you
nger
pat
ient
s as
it m
ay u
nder
estim
ate
seve
rity
in th
ese
patie
nts
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
10
Co
nditi
on
Antib
iotic
Co
mm
ents
Resp
irato
ry
Trac
tIn
fecti
ons
Heal
th ca
reas
socia
ted
pneu
mon
ia5
Hosp
ital a
cquir
edpn
eum
onia
6
Patie
nts f
rom
nursi
ng ho
me/c
hron
ic ca
renu
rsing
facil
ity/r
ecen
t hos
pitali
satio
n ref
er to
algor
ithm
page
11.
With
in 4
days
of ad
missi
on &
no re
cent
antib
iotics
: Co
-am
oxicl
av 6
25m
g TD
S PO
or 1
.2g
TDS
IV
for 8
day
s.
Penic
illin a
llerg
y (NO
T IgE
med
iated
reac
tion
/ana
phyla
xis):
Cefu
roxim
e 750
mg -
1.5g
TDS I
V. Se
vere
IgE m
ediat
ed re
actio
n/an
aphy
laxis
to pe
nicilli
n: Le
voflo
xacin
500
mg PO
/ IV
OD.
(12
hour
ly if
seve
re).
More
than
4 da
ys si
nce a
dmiss
ion :
Pipe
racil
lin-ta
zoba
ctam
4.5
g TD
S IV
If ris
k fac
tors f
or M
DR pa
thog
ens s
ee pa
ge 1
1.
Penic
illin a
llerg
y: if
NOT I
gE
media
ted/a
naph
ylaxis
and i
f pne
umon
ia is
not s
ever
e co
nside
r cef
urox
ime 1
.5g T
DS IV
.Se
vere
IgE m
ediat
ed re
actio
n/an
aphy
laxis
tope
nicilli
n: Le
voflo
xacin
500
mg PO
/IV O
D (1
2ho
urly
if se
vere
).
If pa
tient
is co
nsid
ered
to b
e hig
h ris
kfo
r MRS
A, co
nsid
er a
dding
Teico
plan
in
Send
sput
um fo
r cult
ure i
f pos
sible
Cons
ider l
egion
ella r
isk. I
n at r
isk pa
tient
s se
nd ur
ine fo
r leg
ionell
a ant
igen a
nd ad
d cla
rithr
omyc
in em
pirica
lly. S
end s
putu
m fo
r Le
gione
lla cu
lture
, if po
ssible
For c
onfir
med l
egion
ellos
is se
e pag
e 8.
If pa
tient
is co
nsid
ered
to b
e hig
h ris
kfo
r MRS
A, co
nsid
er a
dding
Van
com
ycin
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
11
Patie
nts w
ith H
CAP s
hould
be id
entifi
ed an
d the
n di
vide
d on
the
basis
of s
ever
ity o
f illn
ess t
o guid
e init
ial th
erap
y. Pa
tient
s in e
ach g
roup
are t
hen
furth
er d
ivid
ed b
ased
on
whe
ther
th
ey h
ave
risk
facto
rs fo
r dru
g-re
sista
nt (M
DR) p
atho
gens
that
includ
e: re
cent
antib
iotic
ther
apy i
n the
past
6 mo
nths
, rec
ent h
ospit
aliza
tion i
n the
past
3 mo
nths
, the
pres
ence
of im
mune
su
ppre
ssion
, and
poor
func
tiona
l stat
us as
defin
ed by
activ
ities o
f dail
y livi
ng. C
AP, c
ommu
nity-
acqu
ired p
neum
onia;
HAP
, hos
pital-
acqu
ired p
neum
onia.
*A
dapte
d fro
m Br
ito V,
et al
. Cur
rent
Opin
ion in
Infe
ctiou
s Dise
ases
200
9, 2
2:31
6-32
5
Alg
ori
thm
for
hea
lthca
re-a
ssoci
ate
d p
neu
monia
(H
CA
P)
ther
apy*
HCA
P p
rese
nt:
Pat
ient
from
nur
sing
hom
e/ch
roni
c ca
re fa
cilit
y, r
ecen
t hos
pita
lizat
ion
Ass
ess se
veri
ty o
f ill
nes
s (U
se C
URB
65 s
core
)
AN
D
Pres
ence
of r
isk
fact
ors
for
mul
ti-dr
ug r
esis
tant
(MD
R) p
atho
gens
(rec
ent a
ntib
iotic
s, r
ecen
t hos
pita
lizat
ion,
poo
r fu
nctio
nal s
tatu
s, im
mun
e su
ppre
ssio
n)
Seve
re p
neu
monia
(Bas
ed o
n C
URB
65 s
core
)
No
(CU
RB65
sco
re m
ild o
r m
oder
ate)
Yes
(CU
RB65
sco
re 3
or
>)
0-1
Risk
s fo
r M
DR
Trea
t for
com
mon
CA
P Pa
thog
ens
See
CA
P p.
8
≥1 R
isk
for
MD
RTr
eat f
or M
DR
Path
ogen
sSe
e H
AP
p.10
≥2 R
isks
for
MD
RTr
eat f
or M
DR
Path
ogen
sSe
e H
AP
p.10
0 Ri
sks
for
MD
RTr
eat a
s se
vere
CA
PSe
e C
AP
p.8
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
12
Co
nditi
on
Antib
iotic
Co
mm
ents
Resp
irato
ry Tr
act
Infe
ction
s
Endo
card
itis
Intra
-abd
omina
linf
ectio
ns
Acut
e ex
acer
batio
n of
COPD
(no c
onso
lidati
on on
CXR)
Exam
ples
: Per
itonit
is,
Dive
rticu
litis,
Bilia
ry tr
act
infec
tions
Panc
reat
itis
Seve
re a
cute
necro
tising
Pan
creat
itis
Antib
iotic
s may
not
be
requ
ired
See “
Comm
ents”
Co-a
mox
iclav
ora
l or I
V de
pend
ing o
nse
verit
y fo
r 5-7
day
s. Re
view
nee
dfo
r IV
ther
apy
on a
dai
ly b
asis.
Penic
illin a
llerg
y : Cl
arith
romy
cin 5
00mg
BD
daily
PO fo
r 5-7
days
Seek
adv
ice fr
om M
icrob
iolo
gy.
Co-a
mox
iclav
1.2
g TD
S IV
for 7
-10
days
.
First
line:
Co-a
mox
iclav
1.2
g TD
S IV
Se
cond
line:
Piper
acilli
n-taz
obac
tam 4
.5g T
DS
IV. Co
nside
r add
ition o
f gen
tamici
n
First
line:
Pipe
racil
lin-ta
zoba
ctam
4.5
g TDS
IV.
Cons
ider a
dditio
n of g
entam
icin
Seco
nd lin
e: Me
rope
nem
1g TD
S IV
Cons
ider a
ntibi
otic t
hera
py if
2 or
mor
epr
esen
t:In
creas
ed br
eath
lessn
ess
Incre
ased
sput
um vo
lume
Sput
um pu
rulen
ceIf
cons
olida
tion o
n CXR
trea
t as C
AP.
Send
3 se
ts of
bloo
d cult
ures
.
Penic
illin a
llerg
y (NO
T IgE
med
iated
reac
tion /
anap
hylax
is):
Cefu
roxim
e 750
mg- 1
.5g T
DS an
d me
tronid
azole
500
mg TD
S IV+
/- ge
ntam
icin.
Seve
re hy
perse
nsitiv
ityre
actio
n/an
aphy
laxis
to pe
nicilli
ns:
metr
onida
zole
+ ge
ntam
icin
Discu
ss wi
th M
icrob
iolog
y tea
m as
soon
as
possi
ble
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
13
Co
nditi
on
Antib
iotic
Co
mm
ents
Gast
ro-in
test
inal
Infe
ction
sAc
ute
gast
roen
terit
is
Clos
tridi
um d
ifficil
eAs
socia
ted
Dise
ase
(CDA
D)
Antib
iotic
Treatm
ent m
ost o
ften n
ot ne
cessa
ry.
Cons
ider
ant
ibio
tics O
NLY
ifim
mun
osup
pres
sed
or si
gns o
fsy
stem
ic se
psis.
Di
scus
s with
micr
obio
logy
team
.
Non-
seve
re C
DAD:
Met
ronid
azol
e 40
0mg
TDS
PO fo
r 10
days
Seve
re C
DAD:
Early
surg
ical r
eview
reco
mmen
ded
Vanc
omyc
in 12
5mg
PO Q
DSfo
r 10
days
Inab
ility t
o tak
e ora
l med
icatio
ns:
Metro
nidaz
ole 5
00 m
g IV T
DS/Q
DS fo
r 10
days
Ensu
re ap
prop
riate
isolat
ion w
ith st
anda
rdan
d con
tact p
reca
ution
s are
insti
tuted
. Sen
dsto
ol sp
ecim
en to
labo
rator
y. No
te a
ll pa
tient
s with
une
xpla
ined
diar
rhoe
a sh
ould
be
isola
ted.
Disc
ontin
ue o
ther
ant
ibio
tics i
fpo
ssib
le.Di
scuss
with
micr
obiol
ogy t
eam
if no
tre
spon
ding t
o the
rapy
.
Refe
r to H
SE SE
Clos
tridiu
m dif
ficile
guide
lines
in th
e Inf
ectio
n Con
trol M
anua
lav
ailab
le on
all w
ards
.8
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
14
Co
nditi
on
Antib
iotic
Co
mm
ents
Sept
icaem
ia
Neut
rope
nic se
psis
9
Asse
ss pa
tient
re po
ssible
focu
sof
infe
ction
–e.g
. urin
ary t
ract,
sk
in/so
ft tis
sue,
abdo
mina
l, ch
est,
neur
ologic
al., c
ommu
nity
or ho
spita
l acq
uired
, tra
vel
histor
y, re
cent
antib
iotic
ther
apy,
pres
ence
of pr
osth
etic
devic
es, in
trava
scular
cath
eters,
etc
.
Ensu
re bl
ood c
ultur
es ta
ken.
See i
ndivi
dual
infec
tion t
reatm
ent g
uideli
nes f
or ap
prop
riate
ther
apy.
Initi
al e
mpi
rical
ther
apy
if no
obv
ious
so
urce
: Pip
erac
illin-
tazo
bacta
m 4
.5g
IV T
DS. C
onsid
er ad
ding g
entam
icin i
f ha
emod
ynam
ically
unsta
ble /
seve
re in
fecti
on.
Cons
ider n
eed f
or ad
dition
al gr
am po
sitive
co
ver e
.g va
ncom
ycin(
or te
icopla
nin if
patie
nt
is alr
eady
on ge
ntam
icin)
Initi
al Em
piric
ther
apy:
Pip
erac
illin-
tazo
bacta
m 4
.5g
QDS
IV. A
dd ge
ntam
icin
if co
mplic
ation
s (e.g
. hyp
otens
ion, p
neum
onia
or an
timicr
obial
resis
tance
susp
ected
).Co
nside
r add
ing va
ncom
ycin
or te
icopla
ninfo
r spe
cific c
linica
l indic
ation
s e.g.
susp
ected
CVC-
relat
ed in
fecti
on or
comp
licati
ons a
s abo
ve.
Penic
illin a
llerg
y (No
t IgE
med
iated
reac
tion/
anap
hylax
is): C
eftaz
idime
2g T
DS IV
plus v
anco
mycin
or te
icopla
nin.
Seve
re Ig
E med
iated
reac
tion/
anap
hylax
is to
penic
illin:
Cipro
floxa
cin pl
us ge
ntam
icin p
lustei
copla
nin
Cons
ider
if p
atien
t at r
isk fo
r inf
ectio
ndu
e to
MRS
A , i
f so,
add
van
com
ycin.
Cons
ider o
ther
mult
iresis
tant
org
anism
s.Ch
eck p
revio
us la
bora
tory r
esult
sPe
nicilli
n alle
rgy:
Gent
amici
n, me
tronid
azole
plu
s teic
oplan
in
At le
ast 2
sets
of b
lood
cultu
res
reco
mm
ende
d fro
m ea
ch lu
men o
f CVC
and p
eriph
eral
OR pe
riphe
ral X
2 if
no CV
C is
pres
ent.
Cultu
re of
urine
, stoo
l, CSF,
skin
and
resp
irator
y spe
cimen
s sho
uld be
guide
d by
clinic
al sig
ns /
symp
toms b
ut sh
ould
not
be p
erfo
rmed
rout
inely.
Pers
isten
t fev
er a
fter 4
day
s of
antib
iotic
ther
apy:
cons
ider
add
ing
empi
ric a
ntifu
ngal
age
nt.
Cons
ider n
eed f
or vi
ral te
sting
&/o
r ant
ivira
lth
erap
y if c
linica
l indic
ation
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
15
Co
nditi
on
Antib
iotic
Co
mm
ents
Bone
and
Joint
Infe
ction
s
Skin
and
soft
tissu
eIn
fecti
ons
Oste
omye
litis
/ Se
ptic
arth
ritis
Cellu
litis,
ery
sipela
s
Necro
tising
soft
tissu
einf
ectio
ns/N
ecro
tising
fa
sciti
s
Hum
an a
nd a
nimal
bite
s
Fluclo
xacil
lin 2
g QD
S IV
plus
sodi
um
fusid
ate
500m
g ta
bs T
DS P
O (o
r fus
idic
acid
susp
. 750
mg
TDS
PO)
Penic
illin a
llerg
y (NO
T IgE
med
iated
reac
tion/
anap
hylax
is): C
efur
oxim
e 1.5
g TDS
IV pl
us fu
sidic
acid
as ab
ove.
Seve
re Ig
E med
iated
reac
tion/
anap
hylax
is to
penic
illin:
Vanc
omyc
in plu
s fus
idic a
cid as
ab
ove.
Benz
ylpe
nicilli
n (p
enici
llin G
) 1.2
g-2.
4gQD
S IV
plus
fluc
loxa
cillin
1-2
g QD
S IV
Penic
illin a
llerg
y (NO
T IgE
med
iated
reac
tion/
anap
hylax
is): C
efur
oxim
e 750
mg-
1.5g
TDS
Seve
re Ig
E med
iated
reac
tion/
anap
hylax
isto
penic
illin:
Clind
amyc
in 1.
2g Q
DS IV
.
Refe
r to
surg
ical t
eam
urg
ently
.Pi
pera
cillin
-tazo
bacta
m 4
.5g
IV 6
to 8
hour
ly p
lus cl
indam
ycin
600m
g-1.
2gQD
S +/
- gen
tam
icin.
Disc
uss w
ith
Micro
biolog
ist.
Co-a
mox
iclav
625
mg
TDS
(or 1
.2g
TDS
IV if
seve
re) f
or 5
day
s
Adjus
t tre
atmen
t whe
n cult
ures
avail
able.
Treat
for 4
to 6
wee
ks. M
onito
r CRP
.
MRS
A kn
own
or h
igh
risk:
van
com
ycin.
Discu
ss po
ssible
oral
switc
h opti
ons w
ith th
e cli
nical
micro
biolog
y tea
m.
Switc
h to fl
uclox
acilli
n 500
mg-1
g QDS
POwh
en cl
inica
l impr
ovem
ent a
chiev
ed. T
reat
for 1
0 da
ys m
inimu
m.
NOTE
: sev
ere
cellu
litis
shou
ld n
ot b
etre
ated
with
a m
acro
lide
(ery
thro
myc
in/cla
rithr
omyc
in).
If MR
SA su
spec
ted us
e van
comy
cin.
Penic
illin a
llerg
y: Do
xycy
cline
100
mg B
D PO
.If
seve
re di
scuss
with
micr
obiol
ogy t
eam.
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
16
Co
nditi
on
Antib
iotic
Co
mm
ents
Cent
ral N
ervo
usSy
stem
ENT
Infe
ction
s
Men
ingiti
s
Ence
phal
itis
Acut
e ep
iglo
ttitis
Tons
illitis
/pha
ryng
itis
Sinu
sitis,
otit
is m
edia
Ceftr
iaxo
ne 2
g BD
IV If
Liste
ria ri
sk ad
dam
oxici
llin 2
g 4 hr
ly IV.
If St
rep p
neum
oniae
(pne
umoc
occu
s) su
spec
ted ad
d van
comy
cinun
til se
nsitiv
ities c
onfir
med.
Treat
for 1
4 da
ys if
pneu
moco
ccus.
Treat
for 7
days
if
menin
goco
ccus.
Seve
re Ig
E med
iated
reac
tion/
anap
hylax
is to
penic
illin:
chlor
amph
enico
l 1g I
V QD
S. If
immu
noco
mpro
mise
d add
vanc
omyc
in an
d co
-trim
oxaz
ole.
Acyc
lovir
10 m
g / kg
IV ev
ery 8
hour
s(u
se id
eal b
ody w
eight
in ob
ese p
atien
ts)
Ceftr
iaxo
ne 2
g BD
IV fo
r 7-1
0 da
ys
Phen
oxym
ethy
lpen
icillin
(pen
icillin
V)
666m
g QD
S PO
for 1
0 da
ysSe
vere
: Ben
zylpe
nicilli
n (pe
nicilli
n G) 1
.2g
QDS I
V
Co-a
mox
iclav
1.2
g IV
/ 6
25m
g TD
SPO
for 5
-7 d
ays
Seek
Micr
obio
logy
adv
ice.
Cons
ider
Dex
amet
haso
ne p
hosp
hate
fo
r bac
teria
l men
ingiti
s.(10
mg IV
6
hour
ly fo
r 2 to
4 da
ys. M
ust c
omme
nce
befo
re or
at sa
me tim
e as a
ntibi
otic).
Send
Blo
od cu
lture
s, th
roat
swab
,ED
TA b
lood
for P
CR +
/- C
SF. I
sola
tepa
tient
. Not
ify P
ublic
Hea
lth.
Adjus
t dos
e in r
enal
impa
irmen
t.Re
ques
t HSV
PCR
on CS
F.
Penic
illin a
llerg
y: Co
nside
r clin
damy
cin +
cipro
floxa
cin fo
r 7-1
0 da
ys.
Penic
illin a
llerg
y: Cla
rithr
omyc
in BD
500
mgPO
for 1
0 da
ys
Penic
illin a
llerg
y: Cla
rithr
omyc
in BD
500
mgPO
for 5
-7 da
ys
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
17
Co
nditi
on
Antib
iotic
Co
mm
ents
Genit
al Tr
act
Infe
ction
Pelvi
c Infl
amma
tory
Dise
ase (
PID)
, Salp
ingitis
, Tu
bo-o
varia
n abs
cess
Outp
atien
t Rx:
Ceftr
iaxon
e 250
mg IM
or IV
as
single
dose
, the
n dox
ycyc
line P
O 10
0 mg
BD
+ me
tronid
azole
PO 4
00mg
TDS
Inpa
tient
Rx:
Ceftr
iaxon
e 1g o
nce d
aily I
V +
doxy
cycli
ne 1
00mg
BD
PO +
metr
onida
zole
PO
400m
g TDS
Seve
re 1
gE m
edia
ted
reac
tion/
ana
phyl
axis
to p
enici
llin: C
linda
mycin
900
mg I
V TDS
+
gent
amici
n (re
fer p
g 19)
+ do
xycy
cline
PO
100
mg B
D
Tota
l dur
atio
n of
ther
apy:
14
days
Switc
h to
ora
l/ou
tpat
ient r
egim
e w
hen
satis
facto
ry re
spon
se fo
r ≥ 2
4 ho
urs.
Note:
Fluo
roqu
inolo
nes (
eg ci
profl
oxac
in or
oflox
acin)
not r
ecom
men
ded
due t
o inc
reas
ing re
sistan
ce. R
ef: M
MWR
59 (R
R-12
)201
0 &
www.
cdc.g
ov/s
td/tre
atmen
t
In pr
egna
ncy,
a mac
rolid
e (az
ithro
mycin
or
eryth
romy
cin) m
ay be
used
inste
ad of
do
xycy
cline
.
Cons
ider t
reati
ng pa
rtner.
Gui
delin
es fo
r th
e em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tal N
etw
ork
June
201
2In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
une
2012
Rev
isio
n D
ate
June
201
3 Re
visi
on n
o 6
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 618
Do
se A
djus
tmen
t Le
vels
Com
men
tsSu
itable
for n
orma
l ren
al fu
nctio
n, cre
atinin
e clea
ranc
e >80
ml/m
in. D
ose
redu
ction
if <
80ml
/min,
seek
advic
e.
NB: G
enta
mici
n do
ses i
n ex
cess
of
400m
g IV
/ d
ay a
re ra
rely
re
quire
d.Do
se sh
ould
nev
er e
xcee
d 50
0mg
IV/D
ay.
See p
age 1
9 fo
r dos
ing al
gorit
him.
Endo
card
itis:
1mg/
kg IV
12
hour
ly.Se
rum
levels
:pr
e-dos
e lev
el <1
μg/m
l1
hour
post
dose
leve
l of 3
-5μg
/ml
(not
alway
s nec
essa
ry).
Norm
al re
nal f
uncti
on: t
wice
-wee
klyse
rum
monit
oring
may
be su
fficie
nt.
Abno
rmal
rena
l fun
ction
: dos
age s
hould
be ad
justed
acco
rding
to cr
eatin
inecle
aran
ce an
d dail
y ser
um as
say
resu
lts.
Take
pre-d
ose l
evel
befo
re th
e 3rd
dose
.
Pre-
dose
leve
ls ar
e re
quire
d to
mon
itor f
orto
xicit
yClo
tted s
ample
16-
18h a
fter t
he fi
rst do
se of
ge
ntam
icin s
hould
be <
1μg
/ml.
If >1
μg/m
l: Che
ck ti
ming
of l
evel,
revi
ew
dosin
g sc
hedu
le, ch
eck
rena
l fun
ction
, co
nsid
er a
ltern
ativ
e th
erap
y an
d se
ek a
dvice
if
nece
ssar
y.Se
e pag
e 19
for d
osing
algo
rithm
.If
cont
inuing
gent
amici
n and
rena
l fun
ction
is st
able,
repe
at lev
el tw
ice w
eekly
. Dail
y lev
els m
ay be
re
quire
d if r
enal
func
tion i
s uns
table.
Note
: 1-h
our p
ost d
ose
levels
are
not
ne
cess
ary
exce
pt in
end
ocar
ditis
– pl
ease
dis
cuss
on an
indiv
idual
basis
(see
comm
ents)
.**
*Clea
rly st
ate do
se, t
ime o
f dos
e and
time o
f bloo
dsa
mple
colle
ction
on th
e req
uest
form
. ***
Once
daily
Am
inogly
cosi
de
pro
toco
l:G
enta
mic
in 5
mg/k
g IV
daily
Infu
se in
100m
l of
glu
cose
5%
or
sodiu
m c
hlo
ride
0.9
% o
ver
30
-60
min
ute
s.
NB A
ntibio
tic
ass
ays
are
done
at
12
:00
Noon a
nd 4
.00
pm
Monday t
o F
riday a
nd
12:0
0 N
oon o
n S
atu
rdays
and S
undays.
Sam
ple
s m
ust
rea
ch t
he
labora
tory
inW
ate
rford
Reg
ional H
osp
ital o
ne
hour
bef
ore
thes
e above
tim
es.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6 19
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
No
No
Yes
Yes
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) Dose50-80 4mg/kg30-50 3mg/kg*10-30 2mg/kg*<10 1-2mg/kg* redose when level <1µg/ml
Is trough level <1µg/ml
Continue current regimen. Check time dose was given andsample taken. Was level taken at
16-18 hours after dose?
Is trough level>1(µg/ml) but<2(µg/ml) andtreatment still
Indicated?
Seek advice from Pharmacy
or Clinical Microbiology
Reduce once daily dose by 1mg/kg*
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)
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)
*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)²IBW (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
NoYes
Yes No
Adult Single Daily Dosing Algorithm for Gentamicin(Exclusions: Endocarditis & renal impairment. Caution required in CF patients,
pregnant women & patients with severe burns.)
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 620
Va
ncom
ycin
Dosa
ge S
ched
ule
Leve
ls Co
mm
ents
(refe
r to d
osing
algo
rithm
page
21)
: 15-
20m
g/kg
(actu
al b
ody
weig
ht).
In se
vere
/com
plica
ted
infec
tions
ahig
her d
ose
+/- l
oadi
ng d
ose
to
achie
ve p
re-d
ose
levels
of 1
5-20
μg/
ml m
ay b
e re
quire
d (s
ee
com
men
ts).
Teico
plan
in do
sage
sche
dule
6 m
g/kg
12
hour
ly fo
r 3 d
oses
and
ther
eafte
r onc
e da
ily. H
igher
dose
s, 10
- 12m
g/kg
, in si
milar
dosin
g sch
edule
is
indica
ted in
serio
us in
fecti
ons e
.g.
MRSA
infe
ction
s and
endo
card
itis. S
uch
patie
nts s
hould
be di
scusse
d with
the
clinic
al mi
crobio
logy t
eam.
Must
be ad
minis
tered
slow
ly IV
at a
maxim
um ra
te of
10m
g/mi
n to a
void
reac
tion s
uch a
s red
man
synd
rome
. In
seve
re/c
ompl
icate
d inf
ectio
ns a
lo
ading
dos
e of
25-
30m
g/kg
can
be
used
to fa
cilita
te ra
pid
atta
inmen
t of
targ
et tr
ough
seru
m v
anco
myc
in co
ncen
tratio
n.Co
mplic
ated I
nfec
tions
:1.
Bac
terae
mia
2. En
doca
rditis
3. O
steom
yeliti
s4.
Men
ingitis
5. H
ospit
al Ac
quire
d Inf
ectio
ns ca
used
by
Staph
aure
usCo
mm
ents
Rena
l impa
irmen
t:If
teico
planin
is to
be us
ed, t
he fu
ll dos
e is
given
for t
he fi
rst 4
days
. The
reaf
ter
exten
ded d
osing
inter
vals
are r
equir
ed.
Colle
ct pr
edos
e lev
el be
fore
4th
dose
of
vanc
omyc
in. G
ive th
e dos
e. An
y adju
stmen
tsne
cessa
ry ca
n be m
ade t
o the
5th
dose
onwa
rds.
Pred
ose
level
shou
ld b
e be
twee
n 10
- 15
μg/m
l. (In
seve
re/c
ompl
icate
dinf
ectio
n 15
-20
μg/m
l). If
cont
inuing
va
ncom
ycin
and r
enal
func
tion i
s stab
le, re
peat
level
twice
wee
kly. D
aily l
evels
may
be re
quire
dif
rena
l fun
ction
is un
stable
. Not
e th
at 1
- hou
r po
st d
ose
levels
are
not
nec
essa
ry.
Clear
ly sta
te do
se, t
ime o
f dos
e and
time o
f bloo
d sa
mple
colle
ction
on th
e req
uest
form
.At
wee
kend
s rou
tine a
ssays
are c
arrie
d out
atmi
dday
on Sa
turd
ays a
nd Su
nday
s.
Leve
lsMa
y be r
equir
ed in
certa
in cir
cums
tance
s eg.
endo
card
itis.
Discu
ss wi
th M
icrob
iolog
y tea
m.
Gly
copep
tides
: V
anco
myci
n &
Tei
copla
nin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6 21
Dosing Algorithm for VancomycinIs 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
Is the patient seriously ill (signs of severe sepsis)?
Give loading dose 25-30mg/kg (Actual body weight)
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 resultLevel Dose Recheck alteration pre-dose level5-10 Increase After adjusted each dose dose given and by 500mg before following morning dose**10-15 Increase After adjusted each dose dose given and by 250mg before following morning dose**15-20 Maintain Twice weekly dosing providing renal regimen function is stable**20-25 Reduce After adjusted each dose dose given and by 250mg before following morning dose**>25 Omit next After adjusted dose and dose given and decrease before following each dose morning dose** by 500mg
Prescribe maintenance dose 15mg/kg BD. (Use Actual body weight) (Preferably at 10am, and 10pm to facilitate 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?
Give loading dose 15mg/kg (Actual body weight)
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 availableOnce daily doses should preferably be given at 10am to facilitate checking of levels
**Unless renalfunction is
deteriorating orspecifically
advised DOSESSHOULD NOT
BE HELD WHILSTAWAITINGLEVELS
Seek advice from Pharmacy
or Clinical Microbiology if
in doubt
Pre-dose level resultLevel Dose Recheck pre-dose alteration level5-10 Increase After adjusted dose each dose given and before by 250mg following morning dose**10-15 Maintain Twice weekly dosing providing renal regimen function is stable**15-20 Reduce After adjusted dose each dose given and before by 250mg following morning dose**>20 Omit next After adjusted dose dose and given and decrease before following each dose morning dose** by 500mg
*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)²IBW (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
Yes
Yes
NoYes No
No
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 622
Exam
ples
of c
hoice
s of s
witc
h fro
m IV
to o
ral r
oute
“N
ote: O
ral A
ntim
icrob
ials a
re si
gnifi
cant
ly les
s cos
tly th
an in
trave
nous
“
IV
ORA
L
Benz
ylpen
icillin
1.2
-2.4
g 4-6
hr
Amox
icillin
500
mg 8
hrAm
oxici
llin 1
g 6 hr
Co-a
moxic
lav 1
.2g 8
hr
Co-a
moxic
lav 6
25mg
8 hr
Clind
amyc
in 60
0mg 6
hr
Clind
amyc
in 30
0mg 6
hrCli
ndam
ycin
1.2g
6 hr
Cli
ndam
ycin
450m
g 6 hr
Fluclo
xacil
lin 1
- 2
g 6 hr
Flu
cloxa
cillin
500
mg -1
g 6 hr
30 m
inutes
befo
re fo
od
Clarit
hrom
ycin
500m
g 12
hr
Clarit
hrom
ycin
500m
g 12
hr
Metro
nidaz
ole 5
00mg
8 hr
Me
tronid
azole
400
mg 8
hr
Cipro
floxa
cin 4
00mg
12
hr
Cipro
floxa
cin 5
00 -
750
mg 1
2 hr
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6 23
ANTIMICROBIALS WITH GOOD ORAL BIOAVAILABILITY
*Sanford Guide 2010** Martindale 33rd
edition***Sanford Guide 2010 and Martindale 33rd
edition
Antimicrobial Oral BioavailabilityCiprofloxacin 70%***
Clindamycin 90%*
Fusidic Acid 91%(tablets)*
Fluconazole 90%*
Levofloxacin 98%*
Linezolid 100%*
Metronidazole 99%**
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 624
RELATIVE COSTS OF ANTIMICROBIALS*
COST OF ONE WEEK’S SUPPLY OF ANTIMICROBIALSBASED 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.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6 25
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 2012Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 626
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.} 2621.2097Dr. B. Carey Ext.Ms. C. Troy, Surveillance Scientist Ext. 2488/2489
Pharmacy Departments.:
WRH Antimicrobial Pharmacist Ext. 2530/2453WGH Antimicrobial Pharmacist Ext. 3261SLKK/Kilcreene Antimicrobial Pharmacist Ext. 5372/5328STGH Antimicrobial Pharmacist Ext. 7119
top related