your hospitals, your health, our priority · 4.3 wounds and lacerations etc. 5 ... accident and...

Date(s) previous version(s) approved (if known):

Version: 1 2 3 4 5 5.1 5.2 6

Date: June 2004 June 2006 November 2007 October 2009 August 2010 February 2011 March 2011 June 2011

DATE OF NEXT REVIEW: July 2016

Manager Responsible for Review: Consultant Microbiologist

your hospitals, your health, our priority

STANDARD OPERATING PROCEDURE:

EMERGENCY FLOOR ANTIBIOTIC SOP

SOP NO: TW10/136 SOP4

VERSION NO: 7

APPROVING COMMITTEE:

MEDICINES MANAGEMENT STRATEGY BOARD

DATE THIS VERSION APPROVED:

MAY 2013

RATIFYING COMMITTEE: PARC (Policy Approval and Ratification Committee)

DATE THIS VERSION RATIFIED:

July 2013

AUTHOR(S) (JOB TITLE) CONSULTANT MICROBIOLOGIST

DIVISION/DIRECTORATE MEDICINE

TRUST WIDE SOP (YES/NO) YES

LINKS TO OTHER POLICIES, SOP’S, GUIDELINES, STRATEGIES ETC:

Antimicrobial Prescribing Policy TW10-136

Clostridium difficile Infection (CDI) Treatment Guidelines

Trust Antibiotic Treatment SOP

Emergency Floor Antibiotic SOP - Version 7 Consultant Microbiologist

Approved: PARC July 2013 Next Review Date:July 2016

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Contents Page No.

1. Policy Statement 2

2. Key Principles 2

3. Limitations 2

4. Treatment Guidelines 3

4.1 Skin and Soft Tissue Infections 3

4.2 Hand and Finger Infections 5

4.3 Wounds and Lacerations etc. 5

4.4 Bites and Stings 6

4.5 ENT Infections 7

4.6 Throat Infections 8

4.7 Maxillo-facial 8

4.8 Chest and Lower Respiratory Tract Infections 9

4.9 Diarrhoea 11

4.10 Urinary Tract Infection 12

4.11 Genitourinary Infections 13

4.12 Trauma and Orthopaedics 14

4.13 Central Nervous System 15

4.14 Abdominal Infections 15

4.15 Sepsis – Immunocompetent Host 16

4.16 Febrile Neutropenia 17

4.17 Prophylaxis 17

5. Human Rights Act 18

6. Accessibility Statement 18

7. Monitoring & Review 18

8. Equality Impact Assessment 18

Appendices

1 References 19

AT ALL TIMES, STAFF MUST TREAT EVERY INDIVIDUAL WITH RESPECT AND UPHOLD THEIR RIGHT TO PRIVACY AND DIGNITY.



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1. POLICY STATEMENT This policy document incorporates information regarding appropriate selection, dosing, route and duration of antimicrobial therapy and prophylaxis for common conditions seen in Accident and Emergency Department. The primary goal of the antimicrobial policy is to inform prescribers in order to optimise clinical outcome while minimising unintended consequences of antimicrobial use, including Clostridium difficile associated disease, toxicity and the emergence of resistance. 2. KEY PRINCIPLES

2.1 Send pus for culture and sensitivity only when you expect the management to be

altered as a result of the test. 2.2 Ensure that any necessary specimens for microbiology are taken before commencing treatment. 2.3 All regimes are for 5 days unless stated otherwise. Doses are for adults. See the BNF for Children for childhood doses. 2.4 Wherever possible give antibiotics by the oral route. Intravenous antibiotics should be reserved for those patients who are unable to take tablets (unconscious/vomiting) or who are systemically unwell and/ or present with a severe infection (meningitis, infective endocarditis, septicaemia).

2.5 Do not use antibiotics by the topical or intramuscular route. The former is ineffective (with the exception of some minor infections), and the latter is unduly painful for the patient. 2.6 Penicillin allergy. It is important to establish the true nature of a reported “allergy” to

penicillin, as the alternative antibiotics may not be as effective or have a higher rate of side effects than penicillin. A history of rash or gastrointestinal symptoms with amoxicillin may not indicate true allergy. Unless signs of immediate type hypersensitivity (anaphylaxis, angio-oedema, bronchospasm, urticaria) were reported, a trial with penicillin may be warranted.

2.7 Always ask about drug allergy and record details in the notes. Consider drug

interactions, liver or renal impairment, pregnancy etc. Patients need clear instructions on how to take their antibiotic.

3. LIMITATIONS This policy is not intended to be comprehensive. Prescribers are advised to consult the BNF and the manufacturers summary of product characteristics for additional information. This is especially relevant for side effects, contraindications, interactions with other drugs and the use of antimicrobials in pregnancy. Advice about individual patients on clinical problems may be obtained from the Consultant Microbiologists: Dr C Faris ext 2153 or Dr R Nelson ext 2943, or via switchboard outside normal working hours.



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4. TREATMENT GUIDELINES

ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

4.1 SKIN AND SOFT TISSUE INFECTIONS

Abscess Incision and drainage. Antibiotics are not indicated.

Impetigo Minor Lesions. Fusidic acid. Topically 6 hourly 5 days

If widespread.

Flucloxacillin oral OR If penicillin allergic, clarithromycin oral

500mg 6 hourly 500mg 12 hourly

7 days

7 days

Cellulitis

See: Community Parenteral Antibiotic

Therapy Guidelines and Formulary NB. Providing there is clinical improvement IVs should be continued until cellulitis subsides, then change to oral antibiotics for 5 further days.

First line - Mild to Moderate:



7 days

Outpatient management of severe cellulitis. Refer to A&E protocol.

Ceftriaxone IV

1-2g daily

Severe/spreading with systemic symptoms: Admit ill patients for IV antibiotics:

Benzylpenicillin IV plus flucloxacillin IV OR If penicillin allergic, teicoplanin IV

1.2g 4-6 hourly 1-2g 6 hourly 400mg every 12 hours for 3 doses then 400mg once daily

7 days

Cellulitis in patients with a history of MRSA colonisation or risk factors such as several hospital colonisations within 6 months of nursing home residency.

Teicoplanin IV 400mg every 12 hours for 3 doses then 400mg once daily

7 days

Orbital cellulitis Following administration of antibiotics refer to Ophthalmology Department immediately. For children, use doses at higher end of cefuroxime dosage range.

Cefuroxime IV plus metronidazole IV

1.5g 8 hourly 500mg 8 hourly

Necrotising fasciitis Prompt surgical debridement is essential, plus combination antibiotic treatment.

Tazocin IV plus clindamycin IV

4.5g 8 hourly 900mg 6 hourly

Pressure sores - Uncomplicated Pressure relief and wound toilet only.

Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (e.g. anaphylaxis, angioedema, facial/throat swelling).



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SKIN AND SOFT TISSUE INFECTIONS cont…..

Pressure sores with progressing cellulitis

First line

Flucloxacillin IV (oral) ± metronidazole oral OR If penicillin allergic, ceftriaxone IV ± metronidazole oral

1g (500mg) 6 hrly 400mg 8 hourly 1g once daily 400mg 8 hourly

7 days

Pressure sores with progressing cellulitis and systemic symptoms

First line Tazocin IV Add teicoplanin if at high-risk of MRSA*

4.5g 8 hourly 7 days

Diabetic foot – Mild infection Cellulitis/ erythema < 2cm AND infection limited to skin or superficial subcutaneous tissue AND NO PREVIOUS antibiotic treatment.

First line

Flucloxacillin oral or IV OR If penicillin allergic, clindamycin oral

1g 6 hourly 450mg 6 hourly

7-14 days

Diabetic foot –Moderate infection Cellulitis extending >2cm OR Lymphangitis OR Deep tissue abscess OR failure of previous antibiotic.

Co-amoxiclav IV (oral) OR If allergic to penicillin, clindamycin IV (oral) plus ciprofloxacin IV (oral)

1.2g (625mg) 8 hourly 600mg (oral 450mg) 6 hourly 400mg (oral 750mg) 12 hourly.

Parenteral therapy until stable then oral antibiotics for up to 4 weeks in the absence of osteomyelitis.

Diabetic foot – Severe infection with systemic symptoms (fever, WBC, CRP), necrosis or osteomyelitis.

Polymicrobial infections. Debridement indicated.

Tazocin IV plus clindamycin IV OR If allergic to penicillin, ciprofloxacin IV (oral) plus clindamycin IV (oral).

4.5g 8 hourly 900mg 6 hourly. 400mg (oral 750mg) 12 hourly 900mg (oral 450mg) 6 hourly.

2-4 weeks.

* Previous MRSA, hospital admissions within 6 months, nursing home resident. Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (e.g. anaphylaxis, angioedema, facial/throat swelling).

IV therapy until stable, then oral antibiotics for 2 to 4 weeks in the absence of osteomyelitis.



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4.2 HAND AND FINGER INFECTIONS

Acute paronychia Incision and drainage. Antibiotics usually not necessary.

Pulp space infection X-ray to exclude osteomyelitis. Incision and drainage under ring or wrist block. A wide elliptical incision is required. Review in A&E Clinic after 48 hours. Antibiotics usually not necessary.

Web space infection Urgent referral to Orthopaedic Surgeons.

Deep palmar space Urgent referral to Orthopaedic Surgeons.

Suppurative tenosynovitis Urgent referral to Orthopaedic Surgeons.

4.3 WOUNDS, LACERATIONS, ETC

Less than 6 hours old NO ANTIBIOTICS Clean, debride and do Primary Closure. Consider antitetanus vaccination.

Delayed presentation If cellulitis is present treat with flucloxacillin.



7 days 7 days

Puncture wounds Consider antitetanus vaccination Flucloxacillin oral OR If penicillin allergic, clarithromycin oral


7 days 7 days

Wound infections No cellulitis = No antibiotics. Consider antitetanus vaccination.



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4.4 BITES AND STINGS

Animal bites Adult: First line Surgical toilet most important. Assess tetanus and rabies risk. Antibiotic prophylaxis may not be indicated for all cases. Antibiotic prophylaxis advised for – puncture wound, bite involving hand, foot, face, joint, tendon, ligament, immunocompromised, diabetic, elderly, asplenic. Child <6 years: 6-12 years:

Co-amoxiclav oral OR If penicillin allergic, ciprofloxacin oral plus clindamycin oral Co-amoxiclav oral If penicillin allergic, seek Microbiology advice. Co-amoxiclav oral

625mg 8 hourly 500mg 12 hourly 450mg 6 hourly 125/31 SF suspension 5ml 8 hourly or 0.25ml/kg 8 hourly 250/62 SF suspension 5ml 8 hourly or 0.15ml/kg 8 hourly

7 days 7 days 7 days 7 days 7 days

Human bites Antibiotic prophylaxis advised. Assess HIV/ hepatitis B & C risk.

See above

Insect bites Treat only if clinically infected. Flucloxacillin oral OR If penicillin allergic, clarithromycin oral


7 days 7 days



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4.5 ENT INFECTIONS

Acute otitis Media Many are viral. 80% resolve without antibiotics. Use NSAID or paracetamol.

No antibiotics.

Acute otitis externa No antibiotics in mild cases. Topical treatment is usually effective in moderate cases. For severe cases:

Topical Otosporin Flucloxacillin oral OR If penicillin allergic, clarithromycin oral

3 drops 6 hourly 500mg 6 hourly 500mg 12 hourly

7 days 5 days 5 days

Malignant otitis externa (Pseudomonas aeruginosa)

Ciprofloxacin is contraindicated in pregnancy and for children.

Ciprofloxacin oral 750mg 12 hourly 7 days

Traumatic rupture of tympanic membrane

Flucloxacillin oral OR If penicillin allergic, clarithromycin oral.


5 days 5 days

Acute mastoiditis First line Amoxicillin oral OR If penicillin allergic, Adults: Oxytetracycline Children: Trimethoprim

500mg 8 hourly 500mg 6 hourly See BNF for Children for dosage information.

7 days 7 days



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4.6 THROAT INFECTIONS

Acute tonsillitis/pharyngitis Mostly viral. Do not require antibiotics. If thought to be bacterial, follicular/ pus present etc. First line

Penicillin V oral OR If penicillin allergic, clarithromycin oral


7-10 days 7-10 days

4.7 MAXILLO-FACIAL

Sinusitis Mostly viral. Reserve antibiotic for severe or persistent symptoms >10days. First line

Amoxicillin oral OR If penicillin allergic, Adults: Doxycycline oral Children: clarithromycin oral

500mg 8 hourly 200mg on day 1, then 100mg 12 hourly See BNF for Children for dosage information.

3-7 days 6 days

Fractures of maxilla

Co-amoxiclav oral OR If penicillin allergic, clarithromycin oral

375mg 8 hourly. 500mg 12 hourly

5 days 5 days

Dental infection/Abscess

First line Abscess will need drainage. Refer.

Penicillin V oral OR If penicillin allergic, metronidazole oral


5 days 5 days



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4.8 CHEST AND LOWER RESPIRATORY TRACT INFECTIONS

Croup Most are viral. No antibiotics indicated.

Epiglottis First line Cefuroxime IV 1.5g 8 hourly

Laryngitis Most are viral. No antibiotics indicated.

Tracheitis Most are viral. No antibiotics indicated.

Infective bronchitis in healthy adults Most are viral. No antibiotics are indicated.

Infective exacerbations of COPD Non-pneumonic chest infections (both community and hospital acquired) Antibiotics indicated if 2 or more of the following: increase in purulence of sputum; increase in volume of sputum; increase in breathlessness.

Most valuable if increased dyspnoea and purulent sputum. If consolidation on CXR treat as for pneumonia (see below).

Consider if antibiotics are needed. Patient not responding to or failed a recent course of doxycycline If nil by mouth.

Doxycycline oral OR

trimethoprim oral co-amoxiclav oral co-amoxiclav IV

200mg stat on day 1 then 100mg 12 hourly 200mg 12 hourly 625mg 8 hourly 1.2g 8 hourly

6 days 5 days 5 days 5 days

Community-acquired pneumonia Evidence of consolidation on CXR. Clinical findings & severity rating using CURB-65 score must be documented:

C = Confusion (AMTS<8) 1 point. U = Urea >7 1 point. R = Respiratory Rate >30 1 point. B = SBP <90 or DBP <60 1 point.

65 = Age >65 1 point.

Mild CURB – 65 score = 0-1

Amoxicillin oral OR If penicillin allergic, doxycycline oral OR

clarithromycin oral

500mg 8 hourly 200mg stat on day 1 then 100mg 12 hourly 500mg 12 hourly


Children less than 6 months: treat as for severe CAP.

6 months - 5 years 5 years – 18 years

Amoxicillin oral Clarithromycin oral/IV

Consult BNFc for dosage instructions.

7-14 days




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CHEST AND LOWER RESPIRATORY TRACT INFECTIONS cont …..

Community-acquired pneumonia

Moderate CURB – 65 score = 2

Amoxicillin (oral or IV) Plus clarithromycin oral OR If penicillin allergic,

ceftriaxone IV plus clarithromycin (oral or IV)

500mg –1g 8 hourly 500mg 12 hourly 1g once daily 500mg 12 hourly


Severe Community-acquired pneumonia Collect sputum and blood cultures if pyrexial. Legionella urinary antigen and nose and throat swabs (VTM) for respiratory viruses.

CURB – 65 score > 3

Co-amoxiclav IV Plus clarithromycin (IV or oral) OR If penicillin allergic,

ceftriaxone IV Plus clarithromycin (IV or oral)

1.2g 8 hourly 500mg 12 hourly 1-2g once daily 500mg 12 hourly


Neonates & children less than 6 months: 6 months - 18 years (atypical pathogens more common in over 5 years)

Cefuroxime IV monotherapy. Cefuroxime IV ± clarithromycin


7-14 days

Post Influenza pneumonia Flucloxacillin IV plus amoxicillin IV OR If penicillin allergic, clindamycin IV

2g 6 hourly 1g 8 hourly 600mg 6 hourly


Community acquired aspiration pneumonia

Benzylpenicillin IV plus metronidazole IV OR If penicillin allergic,

ceftriaxone IV plus metronidazole IV

1.2g 6 hourly 500mg 8 hourly 1g once daily 500mg 8 hourly





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4.9 DIARRHOEA

Viruses Salmonella sp. Campylobacter sp. Shigella sp.

Antibiotic therapy is not usually recommended for cases with mild or moderate diarrhoea. Infection control procedures should be followed in all cases to reduce cross infection (isolation).

Severe diarrhoea (> 6 unformed stools/day, and/or pyrexia, tenesmus, blood in stool)

Campylobacter or shigella suspected. Ciprofloxacin oral 500mg 12 hourly 5 days

Clostridium difficile infection (CDI) Review concurrent antibiotic treatment, PPIs or laxatives and discontinue them where possible. For full details, please refer to „Clostridium difficile infection: Treatment‟ on Microbiology Intranet site.

Initial episode in patient age <75 years with NO severe co-morbidities Initial episode in patient age ≥75 years and/or with severe co-morbidities (immunocompromise, organ failure)

Severe CDI

Life threatening CDI (hypotension, partial or complete ileus or toxic megacolon or CT evidence of severe disease). If ileus is present, then add vancomycin as a retention enema (500mg in 100ml normal saline per rectum 6 – 12 hourly).

Metronidazole oral/ NG If oral route is compromised:

Metronidazole IV

Vancomycin oral/ NG

Vancomycin oral/ NG

If no clinical response, vancomycin dose may be increased: If oral route is compromised:

Metronidazole IV plus intracolonic vancomycin or vancomycin (NG tube) Vancomycin oral/NG plus

metronidazole IV

400mg 8 hourly 500mg 8 hourly 125mg 6 hourly 125mg 6 hourly 500mg 6 hourly 500mg 8 hourly 500mg in 100ml of normal saline every 6 to 12 hours 500mg 6 hourly 500mg 6 hourly 500mg 8 hourly

10 - 14 days 10 - 14 days 10 - 14 days 10 - 14 days 10-14 days

10 – 14 days



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Condition Regimen Penicillin allergy/ Alternative regimens 4.10 GENITOURINARY TRACT INFECTION

Uncomplicated lower UTI Nitrofurantoin # oral 50mg 6 hourly for 3-7 daysŦ.

Patient with eGFR < 60mls/min, co-amoxiclav oral 375mg 8 hourly for 3-7 daysŦ. OR

Cefalexin oral 500mg 12 hourly for 3-7 daysŦ.

UTI in children. Trimethoprim 5 - 7 days Consult BNFc for dosage instructions.

Complicated UTI/Pyelonephritis

Factors suggesting a complicated UTI:

Male patients, pregnant, diabetes mellitus, renal tract abnormalities, recent urinary surgery/instrumentation (excluding urinary tract catheterisation), indwelling urinary catheter, symptoms persisting for over 7 days, recent broad spectrum antibiotics.

Empirical co-amoxiclav oral 625mg (or IV 1.2g) 8 hourly + IV gentamicin* 7mg/kg/day. Duration of treatment: 7-14 days. Gentamicin indicated if there are concerns of multi-drug resistant organisms.

Known sensitivity – trimethoprim oral 200mg 12 hourly. Duration of treatment: 10 days.

Severely ill child:

Ceftriaxone IV for 7 – 14 days


Severe sepsis associated with UTI Tazocin IV 4.5g 8 hourly + IV gentamicin* 7mg/kg/day. Ceftriaxone IV 1-2g once daily + IV gentamicin*

7mg/kg/day.

Catheter-associated UTI (CAUTI)

All catheters become colonised by bacteria and growth of organisms from a CSU is NOT an indication for

antibiotic treatment in the absence of clinical evidence of infection. DO NOT DIPSTIX ON CSUs.

Symptoms suggestive of CAUTI

New loin or suprapubic tenderness

Rigors

New onset delirium

Fever >38oC or 1.5

oC above baseline on two

occasions during 12 hours.

Send urine for culture only if clinically indicted by above symptoms.

Obtain sample from new catheter and await culture results if possible.

Co-amoxiclav PO 625mg 8 hourly + gentamicin* IV 7mg/kg/day (max 560mg). Duration of treatment: 7 days. Gentamicin indicated if there are concerns of multi-drug resistant organisms.

CAUTI with systemic features of sepsis

(Systemically unwell 2 or more of following: Temp>38 or <36, HR >90, RR>20, WBC >12 or <4).

IV tazocin 4.5g 8 hourly + IV gentamicin* 7mg/kg/day.

# Nitrofurantoin - Contraindicated if eGFR <60ml/min. Ŧ For uncomplicated cystitis in women without a catheter give 3 days course; for all other patients give 7 days.

Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (e.g. anaphylaxis, angioedema, facial/throat swelling).

* Consultant Microbiologist/Antimicrobial Pharmacist for dosing advice for patients with renal failure.



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4.11 GENITOURINARY INFECTIONS

Epididymo-orchitis Age < 35yrs Age > 35yrs

Ceftriaxone IM or IV plus Ciprofloxacin oral plus doxycycline oral Ciprofloxacin oral

250mg stat dose 500mg stat dose 100mg 12 hourly 500mg 12 hourly

10 days 10 days

Prostatitis Ciprofloxacin oral 500mg 12 hourly 28 days

Pelvic Inflammatory Disease Empirical treatment: Do full investigation including endocervical swabs for Chlamydia and gonorrhoea. Arrange follow-up with GUM clinic 01942 482083.

If pregnancy test –ve:

Ceftriaxone IM or IV

Doxycycline oral plus metronidazole oral If pregnancy test +ve: Seek Microbiology advice.

250mg stat dose 100mg 12 hourly 400mg 12 hourly

14 days 14 days

† Consult Microbiologist or Antimicrobial Pharmacist for dosing advice for patients with renal failure. Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (e.g. anaphylaxis, angioedema, facial/throat swelling).



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4.12 TRAUMA AND ORTHOPAEDICS

Acute septic arthritis and osteomyelitis

Ideally blood cultures, joint aspirates or biopsy material should be taken prior to starting antibiotics. IV antibiotics are indicated for minimum 2 weeks. Child:

Flucloxacillin IV

plus gentamicin† IV

OR If penicillin allergic, teicoplanin IV plus

gentamicin† IV

Flucloxacillin plus amoxicillin OR cefuroxime

2g 4-6 hourly 7mg/kg once-daily 10-12mg/kg 12 hourly for three doses then same dose once daily 7mg/kg once-daily See BNF for Children for dosage information.

42 days

Compound fractures Consider tetanus vaccine. Co-amoxiclav IV If penicillin allergic, teicoplanin IV ± gentamicin IV + metronidazole IV

1.2g 8 hourly 400mg 12 hourly 1.5mg/kg 12hourly 500mg 8 hourly

1-2 days 3 doses 1-2 days 1-2 days

† Consult Microbiologist or Antimicrobial Pharmacist for dosing advice for patients with renal failure.



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4.13 CENTRAL NERVOUS SYSTEM

Meningitis Neonates (0-3 months) 3 month – 18 years Adults If over 50 years of age or immunocompromised, consider Listeria (add amoxicillin 2g 4 hourly). Consider ciprofloxacin prophylaxis for contacts of cases with meningococcal meningitis.

Cefotaxime IV plus amoxicillin IV

Ceftriaxone IV

Ceftriaxone IV If penicillin allergic, Seek Microbiology advice.

See BNF for Children for dosage information.

2g 12 hourly

Variable according to pathogen.

Encephalitis Mostly viral. Herpes simplex encephalitis.

Aciclovir IV

10mg/kg 8 hourly

14 - 21 days

4.14 ABDOMINAL INFECTIONS

Acute appendicitis Antibiotics are NOT indicated for uncomplicated cases but should be given if patient is unwell and/or septic.

Co-amoxiclav IV OR If penicillin allergic, Tigecycline IV

1.2g 8 hourly 100mg once then 50mg 12 hourly

5 days

5 days

Perforated abdominal viscus Localised abdominal abscess Generalised peritonitis

Co-amoxiclav IV OR If penicillin allergic, Tigecycline IV

1.2g 8 hourly 100mg once then 50mg 12 hourly

5 days

5 days

Cholecystitis, Cholangitis Tazocin IV OR If penicillin allergic, Tigecycline IV

4.5g 8 hourly 100mg then 50mg 12 hourly

Diverticulitis Tazocin IV If penicillin allergic, Tigecycline IV

4.5g 8 hourly 100mg then 50mg 12 hourly




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4.15 SEPSIS IMMUNOCOMPETENT HOST

No obvious focus of infection Add teicoplanin if at high risk of

MRSA*.

Tazocin IV + gentamicin

† IV

OR If penicillin allergic, teicoplanin IV for 3 doses then once daily plus gentamicin

† IV plus

metronidazole IV.

4.5g 8 hourly 7mg/kg once-daily 10-12mg/kg 12 hourly 7mg/kg/day 500mg 8 hourly

7-14 days

Associated with intra-abdominal source Tazocin IV + gentamicin

† IV

OR If penicillin allergic, tigecycline IV + gentamicin

† IV

4.5g 8 hourly 7mg/kg once-daily 100mg once then 50mg 12 hourly 7mg/kg once-daily

7 days

Associated with soft tissue/ skin infections

Flucloxacillin IV plus benzylpenicillin IV OR If penicillin allergic, teicoplanin IV

1-2g 6 hourly 1.2g 4-6 hourly 400mg 12 hourly for 3 doses then 400mg daily.

7-14 days

Associated with urinary tract Tazocin IV + gentamicin

† IV

OR If penicillin allergic,

ceftriaxone IV ± gentamicin

† IV

4.5g 8 hourly 7mg/kg once-daily 1-2g once daily 7mg/kg/day

7-14 days

Associated with chest infection See recommendations for severe CAP or HAP.

Septicaemia in IV drug users Flucloxacillin IV plus gentamicin

† IV

2g 6 hourly 7mg/kg once-daily

7-14 days

* Previous MRSA, hospital admissions within 6 months, nursing home resident. † Consult Microbiologist or Antimicrobial Pharmacist for dosing advice for patients with renal failure.




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Neonatal sepsis (< 3 months)

Group B Streptococcus suspected. Listeria, GBS or coliforms suspected.

Benzylpenicillin IV plus gentamicin IV OR Amoxicillin IV plus

cefotaxime IV

See BNF for Children for dosage information.

Septicaemia in children (3 months – 18 years)

Ceftriaxone IV See BNF for Children for dosage information.

4.16 FEBRILE NEUTROPENIA

Low-risk patient Refer to full guidelines on the Intranet. Co-amoxiclav oral plus ciprofloxacin oral


High-risk patient Indications for teicoplanin: severe mucositis, h/o ciprofloxacin prophylaxis, IV catheter sepsis, known/suspected MRSA colonisation.

Meropenem IV +/- teicoplanin IV If penicillin allergic seek microbiology advice.

1g 8 hourly 400mg 12 hourly for 3 doses, then 400mg once-daily.

4.17 PROPHYLAXIS

Prevention of infective endocarditis

Refer to “Antibiotic Prophylaxis Guidance for Splenectomy, Meningococcal disease, H Influenzae type b disease and Endocarditis” available on Microbiology Intranet site.

Prevention of secondary cases of meningococcal disease

Adult and children over 12 years Pregnancy Children 5-12 years Children 1 month to 4 years If ciprofloxacin is contraindicated consider Rifampicin. Refer to full guidelines on Microbiology Intranet site.

Ciprofloxacin oral

500mg 500mg 250mg 125mg

STAT

HIV Post exposure prophylaxis

Refer to Occupational Health Policy on Post exposure Prophylaxis available on Infection Control Intranet site. Refer to Inoculation Injury in the Community setting on the Microbiology Intranet site.

One Truvada tablet (tenofovir + emtricitabine) plus two Kaletra film coated tablets (lopinavir+ritonavir)

Once daily 12 hourly

28 days

Hepatitis B prophylaxis following percutaneous injury

Refer to the A&E Protocol for the management of needlestick injuries.




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5. HUMAN RIGHTS ACT Implications of the Human Rights Act have been taken into account in the formulation of this policy and they have, where appropriate, been fully reflected in its wording. 6. ACCESSIBILITY STATEMENT This document can be made available in a range of alternative formats e.g. large print, Braille and audiocassette. Form more details please contact HR Department on 01942 77(3766) or email [email protected] 7. AUDIT MONITORING AND REVIEW: The processes contained within this SOP will be; audited, monitored and reviewed in line with the audit and monitoring template contained within Antimicrobial Prescribing Policy TW10-136. 8. EQUALITY AND DIVERSITY ASSESSMENT: The completed assessment is contained within the associated Antimicrobial Prescribing Policy TW10-136.

mailto:[email protected]



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APPENDIX 1 REFERENCES: BNF 65; March – September 2013. Infections; 334-435. BNF for Children, 2005. Infections; 265-375. Bone and Joint Infection: Anon. The Management of Septic Arthritis. Drug & Therapeutics Bulletin, 2003; 41:65-68. Bone and Joint Infections in: Antibiotic and Chemotherapy. Edited by O‟Grady F, Lambert H, Finch RG, Greenwood D. 7th Ed, Churchill Livingstone, Edinburgh 1997. CNS Infection: McGrath N, Andeson NE, Croxson Mc and Powell KF. Herpes simplex encephalitis treated with acyclovir, diagnosis and long term outcome. J Neurol Neurosurg Psychiatry, 1997; 63: 321-326. Heydermnan RS, Lamber HP, O‟Sullivan I, et al. Early Management of Suspected Bacterial Meningitis and Meningococcal Septicaemia in Adults. Journal of Infection, 2003; 46(2): 75-77. British Infection Society. Consensus statement on diagnosis, investigation, treatment and prevention of acute bacterial meningitis in immunocompetent adults. Journal of Infection 1999; 39; 1-15. Gastrointestinal Infection: British Society for the Study of Infection. The Management of Infective Gastroenteritis in Adults. Journal of Infection. 1996; 33: 143-152. Genitourinary Infection: Anon. Guideline No.32: Management of Acute Pelvic Inflammatory Disease. Royal College of Obstetricians and Gynaecologists, London 2003. Foster G. Treatment of pelvic inflammatory disease in primary care. Prescriber‟s Journal. 1998; Vol. 38 No. 2. Anon. SIGN 88. Management of suspected bacterial urinary tract infections in adults, July 2012. Respiratory Infection: Anthonisen MD, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson A. Antibiotic Therapy in Exacerbations of Chronic Obstructive Pulmonary Disease. Annals of Internal Medicine, 1987; 106: 196-204. Anon. British Thoracic Society Guidelines on Management of Community-acquired Pneumonia in Adults. Thorax, 2001; 56 (suppl 4) & 2004 Update & 2009 Update. Kozyrski AL, Hildes Ristein E, Longstaffe SEA, Wincott JL, Sitar DS, Klassen TP. Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis. JAMA, 1998; 279: 1736-1742. O‟Neill P and Roberts R. Acute Otitis Media, in Clinical Evidence, London, BMJ Publishing Group, 2003; 9: 274-286.



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Swart Sjoerd, Saches APE, Ruijs G, Gubbels JW, Hoes AW, de Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults. British Medical Journal, 2000; 320: 150-154. Del Mar C and Glaziou P. Upper respiratory tract infections, in Clinical Evidence, London, BMJ Publishing Group, 2003; 9: 1701-1711. Skin and Soft Tissue Infection: Morgan M. The bacteriology and clinical aspects of bites. CPD Infection, 2003; 4(2): 44-48. Cummings PL. Antibiotics to prevent infection in patients with dog bites wounds – a meta-analysis of randomized trials. Annals of Emergency Medicine, 1994; 23: 535-540. Antibiotic prophylaxis for mammalian bites. (Cochrane Review). Cochrane Library, Issue 3, 2003, Update Software. Anon. Dilemmas when managing cellulitis. Drug and Therapeutics Bulletin, 2003, 41: 43-46.

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