Post on 01-Jan-2020
Guidelines for the empiric use of antimicrobials in adults
University Hospital WaterfordSouth Tipperary General HospitalKilcreene Orthopaedic HospitalSt. Luke’s General Hospital, KilkennyWexford General Hospital
July 2016
Review Date: July 2017
Acknowledgement: Gentamicin and Vancomycin Algorithims pages 27 & 31 adapted from original algorithims kindly provided by Beaumont/Connolly Hospital Antimicrobial Stewardship Committee in 2014.
Issued in June 2006Revised Annually Revision No 10Review Date July 2017HSE SE Antimicrobial Stewardship Group
Disclaimer:Whilst every effort has been made to ensure the accuracy of the information and material contained in this document, errors or omissions may occur in the content. We acknowledge that new evidence may emerge that may overtake some of these recommendations. The document will be reviewed and revised annually. Prescribers should ensure that the correct drug and dose is prescribed, as is appropriate for each individual patient. References that should be used in conjunction with these guidelines include the British National Formulary (BNF) and the drug data sheets (available on www.medicines.ie). Clinical guidelines are guidelines only and the interpretation and application of the guidelines remains the responsibility of the individual clinician.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
1
Table of Contents Page No. General Guidance 2 - 3Restricted and Reserve Antimicrobials 4MRSA 5 Start Smart Then Focus Care Bundle 6 - 7SepSiS - Evaluation and Management 8Adult Sepsis Management Algorithm (NCEC) 9Septicaemia/Systemic Sepsis, Sepsis in Pregnancy, Neutropenic Sepsis 10 - 11Sepsis Guide 12 - 13Urinary Tract Infection 14Respiratory Tract Infection 15Endocarditis & Intra-abdominal Infections 20 Gastro-intestinal Infection 21Genital Tract Infection 22Bone and Joint Infections 23Skin and Soft tissue Infections 23Central Nervous System 24ENT infections 24 Appendix 1: Start Smart, Then Focus Care Bundle 25Appendix 2: Gentamicin 26 - 27Appendix 3: Amikacin 28 - 29Appendix 4: Glycopeptides: Vancomycin, Teicoplanin 30 - 31Appendix 5: Treatment of Clostridium difficile Infection 32 - 33Appendix 6: Switch from IV to PO 34 - 35Appendix 7: Relative Costs of Antimicrobials 36Appendix 8: Tips on Clinical Assessment of Patients following Notification of Positive Blood Culture and Gram Stain. 37Appendix 9: Guidelines for Consultation with the Clinical Microbiology Advisory Team (C-MAT), University Hospital Waterford 41Appendix 10 : Dose adjustment in renal impairment 42 - 43Appendix 11: Formula for weight calculations 43 - 44Appendix 12: Other guideline documents to consider in association with these guidelines. 45Appendix 13: Penicillin Allergy 46Contact Numbers 47References 48 - 49
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
2
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
indica
tion f
or th
erap
y and
inten
ded d
urati
on in
med
ical r
ecor
d. No
te the
se gu
idelin
es ar
e inte
nded
for
empir
ic the
rapy
. Rati
onali
se w
hen m
icrob
iolog
y res
ults b
ecom
e ava
ilable
. It is
the
resp
onsib
ility
of th
e pe
rson
/tea
m or
derin
g lab
orat
ory
test
s to
follo
w u
p on
the
resu
lts to
guid
e ap
prop
riate
clini
cal
mana
geme
nt o
f the
pat
ient.
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, l
evofl
oxac
in, so
dium
fusid
ate
and m
etro
nidaz
ole h
ave
exce
llent
ora
l bio
avai
labi
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
shou
ld on
ly be
used
if th
e pati
ent is
not a
bsor
bing
or u
nabl
e to
hav
e or
al m
edica
tions
.
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
3
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 34.
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
ben
zyl p
enici
llin to
PO
amox
icillin
as or
al ab
sorp
tion o
f pen
icillin
is ve
ry po
or.
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 fluo
roqu
inolon
es (e
.g.
levofl
oxac
in an
d cipr
oflox
acin)
, clin
damy
cin an
d cep
halos
porin
s.
11.
Note
that
sodi
um fu
sidat
e ac
id a
nd ri
fam
picin
shou
ld n
ever
be
used
as m
onot
hera
py
12.
Note
on M
acro
lides
(eg e
ryth
romy
cin, c
larith
romy
cin):
This
class
of an
tibiot
ics ha
s a nu
mber
of si
de ef
fects
, int
erac
tions
and c
ontra
indica
tions
that
shou
ld be
take
n int
o acco
unt w
hen p
rescr
ibing
. Cau
tion s
hould
be
parti
cular
ly ex
ercis
ed in
patie
nts w
ith ca
rdiac
histo
ry an
d the
elde
rly.
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
4
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 Hospitals.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 Hospitals Guidelines for use of Reserve and Restricted Antimicrobials for details.
Restricted Antimicrobials *Reserve Antimicrobials IV Piperacillin/Tazobactam IV Cefotaxime IV Ceftazidime IV/PO OfloxacinIV Ceftriaxone IV ColistinIV/PO Ciprofloxacin IV/PO LinezolidIV/PO Levofloxacin IV DaptomycinIV Chloramphenicol IV TigecyclineIV/PO Clindamycin PO FidaxomicinIV Teicoplanin IV CeftarolineIV Vancomycin IV/PO FosfomycinIV Meropenem IV AztreonamIV Amikacin IV Cefazolin IV Ertapenem IV/PO Tedizolid IV/PO Moxifloxacin 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.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
5
MRSA (Meticillin Resistant Staphylococcus aureus)
Infection with MRSA should be suspected if: • Patient has previously been colonized with MRSA.
(Please check patient notes, laboratory results and any currently in use/appropriate Infection Control alerts such as Laboratory SIF code, IPMS Infection Control alert, etc.)
• 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 most recent edition of: Policy on Control and Prevention of Meticillin Resistant Staphylococcus aureus (MRSA) in Acute Hospitals in the HSE/SE for additional information)
If MRSA infection is suspected, consider including a glycopeptide (Vancomycin or Teicoplanin, see page 30-31) in the empiric treatment regimen.
MRSA eradication: Please refer to most recent edition of: Policy on Control and Prevention of Meticillin Resistant Staphylococcus aureus (MRSA) in Acute Hospitals in the HSE/SE.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
6
Day 1: Start Smart... ...then Focus (Day 2 onwards)nwards
Start Smart, Then Focus
7
Day 1: Start Smart... ...then Focus (Day 2 onwards)nwards
Start Smart, Then Focus
8
1 Consider Sepsis
Sepsis =Known or Suspected Infection & Systemic Inflammatory Response Syndrome (SIRS)Defined as the presence of 2 or more of the following:
Temperature >38°C or <36°C
Respiratory Rate >20 breaths per min
PaCo2 <4.3 kPa
Heart Rate >90 beats per min
White Cell Count > 12 or <4
Evaluation and Management of a patient with suspected
Sepsis
3. Assess patient to determine possible Sourcel Urinary Tractl Skin, soft tissue, bone, jointl Abdominal, pelvicl Respiratory Tract infectionl Intravascular catheter or prosthetic devicel Travel historyl Recent antibiotic treatment
2 Intervention - Action within one hour
COMPLETE SEPSIS SIX
1. High Flow Oxygen 4. Urine output measurement
2. Lactate Check 5. CULTURES*
3. Fluid Challenge 6. Antimicrobial Therapy
(*blood, wounds, sputum, urine, CSF, invasive line sites etc. as appropriate)
Source Known Source Unknown
**Refer to relevant section of this guideline for empiric therapy**
ASSESS FOR RISK OF RESISTANT ORgANISmS22 (ref Irish MDRO guidelines)
1. Check MDRO Flag on IPMS/Health Care Record/WRLAB2. Check previous Microbiology results
Stable Unstable - Life Threatening Sepsis
Piperacillin/Tazobactam (Tazocin) 4.5g tds +/- gentamicin *If hypotensive or severe infection add gentamicin, see page 26-27 for dose & monitoring.
PEN ALLERGY: Teicoplanin, Gentamicin, Metronidazole
MRSA See page 5 of guidelines for risk factors for MRSA Add vancomycin (or teicoplanin if patient already on gentamicin), see page 31 for dosing.
Piperacillin/Tazobactam 4.5g tds + amikacin, Refer to page 28-29 for dosing & monitoring of amikacin.
PEN ALLERGY: Teicoplanin, Amikacin, Metronidazole
MRSA See page 5 of guidelines for risk factors for MRSA Add vancomycin (or teicoplanin if patient already on gentamicin), see page 31 for dosing.
5. Refer to Adult Sepsis management Algorithm (Opposite page), NEWS Score & National Sepsis Guidelines14
6. Rationalise antimicrobial therapy when results of Blood cultures and Microbiology results available.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
4. Antimicrobial Therapy
9
Adult Sepsis Management Algorithm
Guidance to be read in conjunction with National Clinical Guideline No. 6 Management of Sepsis in Ireland
Further informationwww.health.gov.ie/patient-safety/ncecwww.hse.ie/sepsiswww.hse.ie
** SBP: Systolic Blood Pressure
14
Adult Sepsis Management Algorithm
Hypotension: *MAP ≤ 65mmHG or**SBP < 90mmHgor** SBP decrease > 40mmHG in Adults or < 2 SD below normal for age 14
10
Co
nditi
on
Antib
iotic
Co
mm
ents
Sept
icaem
ia/
Syst
emic
Seps
isAs
sess
patie
nt re
possi
ble fo
cus
of in
fecti
on –
e.g. u
rinar
y tra
ct,
skin/
soft
tissu
e, ab
domi
nal,
ches
t, ne
urolo
gical.
, com
munit
yor
hosp
ital a
cquir
ed, t
rave
lhis
tory,
rece
nt an
tibiot
ic th
erap
y, pr
esen
ce of
pros
theti
c de
vices
, intra
vascu
lar ca
thete
rs,
etc.
Wat
ch fo
r hyp
oten
sion
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 eg
ESBL
, VRE
, CRE
.
Chec
k pre
vious
labo
rator
y res
ults
Ensu
re bl
ood c
ultur
es ta
ken.
See
indiv
idua
l inf
ectio
n tre
atm
ent g
uideli
nes f
or
appr
opria
te th
erap
y. R
efer
to N
EWS S
core
of
the a
dult p
atien
t obs
erva
tion c
hart
and
Seps
is Six
.
Ratio
nalis
e w
ith re
sults
of b
lood
cu
lture
ID a
nd se
nsiti
vitie
s
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)
Penic
illin a
llerg
y: Ge
ntam
icin,
metro
nidaz
ole
plus t
eicop
lanin
Seve
re se
psis
(life
thre
atenin
g) us
e ami
kacin
ins
tead
of g
entam
icin,
espe
cially
if m
ulti-d
rug
resis
tance
susp
ected
. Lev
els m
ust b
e mon
itore
d. (S
ee pa
ge 2
8-29
for d
osing
).
Adap
ted fr
om: H
SE A
dult P
atien
t
Obse
rvati
on Ch
art.
12
See a
lso N
ation
al Se
psis
Guide
line
on pa
ge 1
2 an
d 13.
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
11
Co
nditi
on
Antib
iotic
Co
mm
ents
Neut
rope
nic se
psis9
Pleas
e also
refe
r to
secti
on on
seve
re se
psis
(life
thre
atenin
g) on
pr
eviou
s pag
e
Seps
is in
Preg
nanc
y
Neut
rope
nia =
Neu
troph
il Co
unt <
1.0
Seve
re N
eutro
penia
=
Neut
roph
il Cou
nt <
0.5
Feve
r = Te
mper
ature
> 3
80 C
Refe
r to
Sept
icaem
ia/
Syst
emic
Seps
is on
p10
. Cli
nical
featu
res s
ugge
stive
of
seps
is in
preg
nant
wom
en:
Feve
r/Rig
ors,
Diar
rhoe
a/Vo
mitin
g, Ra
sh, A
bdom
inal/
Pelvi
c Pain
and T
ende
rnes
s, Of
fens
ive Va
ginal
Disch
arge
, Co
ugh,
Urina
ry Sy
mtom
s.11
Initi
al Em
piric
ther
apy:
Pipe
racil
lin-
tazo
bacta
m 4.
5g Q
DS IV
. Add
genta
micin
if
comp
licati
ons (
e.g. h
ypote
nsion
, pne
umon
ia or
an
timicr
obial
resis
tance
susp
ected
or cr
iticall
y ill).
Cons
ider a
dding
vanc
omyc
in or
teico
planin
for sp
ecifi
c clin
ical in
dicati
ons e
.g. su
spec
tedCV
C-rela
ted in
fectio
n or c
ompli
catio
ns as
abov
e.Pe
nicilli
n alle
rgy (
Not S
ever
e rea
ction
/an
aphy
laxis)
: Ceft
azidi
me 2g
TDS I
Vplu
s van
comy
cin or
teico
planin
.Se
vere
reac
tion/
anap
hylax
is to
penic
illin:
Cipro
floxa
cin pl
us ge
ntami
cin pl
ustei
copla
nin
Initi
al e
mpi
rical
ther
apy:
Pipe
racil
lin-ta
zoba
ctam
4.5
g IV
TDS
. Co
nside
r add
ing ge
ntam
icin 3
-5mg
/kg
once
daily
11 (u
se bo
oking
weig
ht) 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 t
eicop
lanin
if pa
tient
is
alrea
dy on
gent
amici
n)Ad
d clin
damy
cin if
inva
sive G
roup
A St
rep
Infe
ction
susp
ected
. Sev
ere s
epsis
(life
th
reate
ning)
use m
erop
enem
1-2
g TDS
.
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
Refe
r to N
EWS/
MEOW
S Sco
re an
d Sep
sis
Six. R
eleva
nt im
aging
stud
ies sh
ould
be
perfo
rmed
prom
tly.
Info
rm Co
nsult
ant O
bstet
rician
Refe
r to
Criti
cal C
are
Team
and
seek
ex
pert
advi
ce fr
om m
icrob
iolo
gist
w
hen
seve
re se
psis
is su
spec
ted.
Re
fer t
o RCO
G Gu
idelin
e: Ba
cteria
l Infe
ction
in
Preg
nanc
y for
furth
er de
tailed
guida
nce.11
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
12
Clinica
l Strat
egy an
d Prog
ramme
s Divis
ion
A
IS SE
PSIS
SUSP
ECTE
D?
NEWS
≥ 4 (
5 on s
upple
menta
ry O 2)
ARE A
NY 2
OR M
OREM
ODIFI
EDSIR
S CRIT
ERIA
PRES
ENT?
I f Yes
: THI
S IS S
EPSIS
S
SEPS
IS SIX
– AIM
TOCO
MPLE
TE W
ITHIN
1 HOU
R
Look
for s
igns o
f orga
n dys
functi
on:
SEVE
RE SE
PSIS
An
y orga
n dys
functi
on: T
HIS I
S SEV
ERE S
EPSIS
R egis
trar o
r Con
sulta
nt to
review
imme
diatel
y.
A
Look
for s
igns o
f sep
tic sh
ock
(follo
wing
admi
nistra
tion o
f fluid
bolus
)
SEPT
IC SH
OCK
If eith
er pr
esen
t: THI
S IS S
EPTIC
SHOC
KCr
itica
l car
e con
sult r
equir
ed
Clinica
l Strat
egy an
d Prog
ramme
s Divis
ion
A
IS SE
PSIS
SUSP
ECTE
D?
NEWS
≥ 4 (
5 on s
upple
menta
ry O 2)
ARE A
NY 2
OR M
OREM
ODIFI
EDSIR
S CRIT
ERIA
PRES
ENT?
If Yes
: THI
S IS S
EPSIS
S
SEPS
IS SIX
– AIM
TOCO
MPLE
TE W
ITHIN
1 HOU
R
Look
for s
igns o
f orga
n dys
functi
on:
SEVE
RE SE
PSIS
An
y orga
n dys
functi
on: T
HIS I
S SEV
ERE S
EPSIS
Regis
trar o
r Con
sulta
nt to
review
imme
diatel
y.
A
Look
for s
igns o
f sep
tic sh
ock
(follo
wing
admi
nistra
tion o
f fluid
bolus
)
SEPT
IC SH
OCK
If eith
er pr
esen
t: THI
S IS S
EPTIC
SHOC
KCr
itica
l car
e con
sult r
equir
ed
13
14
Urina
ry Tr
act
Infe
ction
s³Lo
wer
urin
ary
tract
infec
tion
(unc
ompli
cated
)/UT
I in fe
males
.
Hosp
ital a
cquir
ed o
r re
curre
nt U
TI o
rco
mpl
icate
d UT
I/UT
I in
men
.
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
days
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.
Penic
illin a
llerg
y; ge
ntam
icin (
see p
age 2
6 fo
r dos
ingre
gimen
) and
revie
w at
48 ho
urs.
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,
use c
o-am
oxicl
av
(If no
t alle
rgic
to pe
nicilli
n (dis
cuss
if ne
eded
))In
preg
nanc
y nitr
ofur
antoi
n may
also
be us
ed
but it
shou
ld be
avoid
ed at
term
.
Patie
nts w
ith re
curre
nt U
TIs m
ay ha
vere
sistan
t org
anism
s. Us
e 7-
10 d
ays
treat
men
t in
mal
es.
Send
bloo
d cult
ures
and M
SU. R
atio
nalis
eth
erap
y as
soon
as p
ossib
le. C
heck
cu
lture
and
ant
imicr
obia
l sen
sitiv
ity
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 the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
15
COM
MU
NIT
Y A
CQU
IRED
PN
EUM
ON
IA
Base
d o
n “B
ritis
h Th
oraci
c So
ciet
y gui
del
ines
for
the
mana
gem
ent
of
com
mun
ity a
cqui
red p
neum
onia
in a
dul
ts: U
pdate
2009.”
4
Thes
e gu
idel
ines
are
not
aim
ed a
t: (a
) Pat
ient
s w
ith k
now
n pr
edisp
osin
g co
nditi
ons
such
as
canc
er o
r im
mun
osup
pres
sion
adm
itted
with
pn
eum
onia
to s
peci
alis
t uni
ts s
uch
as o
ncol
ogy,
hae
mat
olog
y, p
allia
tive
care
, inf
ectio
us d
iseas
e un
its
or 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 “ch
est i
nfec
tions
”
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 the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
16
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
Legi
onell
osis
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
) Disc
uss w
ith M
icrob
iolo
gist
.
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 the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
17
CURB6
5 s
core
New
ons
et m
enta
l con
fusio
nU
rea>
7 m
mol
/LRe
spira
tory
rate
≥ 3
0/m
inSy
stol
ic b
lood
pre
ssur
e <9
0mm
Hg
and/
ordi
asto
lic b
lood
pre
ssur
e ≤6
0mm
Hg
Age
≥65
yea
rs
Low
risk
0 or
1 p
oint
Inte
rmed
iate
risk
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
omm
ended
the
rapy
for
Com
mun
ity A
cqui
red P
neum
onia
(Tak
en fr
om J
Ant
imic
rob
Che
mot
her 2
012;
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 the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
18
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 (in
cludi
ng
aspi
ratio
n pn
eum
onia
)Wi
thin 4
days
of ad
missi
on
& no
rece
nt an
tibiot
ics:
More
than
4 da
ys si
nce
admi
ssion
:
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
19.
Co-a
moxic
lav 62
5mg T
DS PO
or 1.
2g TD
S IV
for 8
days
.Pe
nicilli
n alle
rgy (
NOT I
gE m
ediat
ed re
actio
n/a
naph
ylaxis
): Ce
furo
xime 7
50 m
g -1.
5g TD
S IV.
(add
me
tronid
azole
in as
pirati
on pn
eumo
nia).
Seve
re Ig
E med
iated
reac
tion/
anap
hylax
is to
penic
illin:
Levo
floxa
cin 5
00mg
PO /
IV O
D. (1
2 ho
urly
if se
vere
). (a
dd
metro
nidaz
ole in
aspir
ation
pneu
monia
).
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
9.Pe
nicilli
n alle
rgy:
if NO
T IgE
me
diated
/ana
phyla
xis an
d if p
neum
onia
is no
t sev
ere c
onsid
er
cefuro
xime 1
.5g TD
S IV.
(add m
etron
idazo
le in
aspira
tion p
neum
onia)
.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
). (a
dd m
etron
idazo
le in
aspir
ation
pneu
monia
).
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 16.
If pa
tient
is co
nsid
ered
to b
e hig
h ris
kfo
r MRS
A, co
nsid
er a
dding
Va
ncom
ycin.
De-e
scal
ate
base
d on
cultu
re re
sults
w
here
pos
sible.
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
19
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
orith
m f
or h
ealth
care
-ass
ocia
ted p
neum
onia
(H
CAP)
the
rapy*
HCA
P pre
sent
: Pat
ient
from
nur
sing
hom
e/ch
roni
c ca
re fa
cilit
y, re
cent
hos
pita
lizat
ion
Ass
ess se
veri
ty o
f ill
ness
(Use
CU
RB65
sco
re)
AN
D
Pres
ence
of r
isk fa
ctor
s fo
r mul
ti-dr
ug re
sista
nt (M
DR)
pat
hoge
ns(a
ntib
iotic
s in
pas
t 6 m
onth
s, h
ospi
taliz
atio
n in
pas
t 3 m
onth
s, p
oor f
unct
iona
l sta
tus,
imm
une
supp
ress
ion)
Seve
re p
neum
onia
(Bas
ed o
n C
URB
65 s
core
)
No
(CU
RB65
sco
re m
ild o
r mod
erat
e)Ye
s (C
URB
65 s
core
3 o
r >)
0-1
Risk
s fo
r MD
RTr
eat f
or c
omm
onC
AP
Path
ogen
sSe
e C
AP
p.17
≥1 R
isk fo
r MD
RTr
eat f
or M
DR
Path
ogen
sSe
e H
AP
p.18
≥2 R
isks
for M
DR
Trea
t for
MD
R Pa
thog
ens
See
HA
P p.
18
0 Ri
sks
for M
DR
Trea
t as
seve
re C
AP
See
CA
P p.
17
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
20
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
Cons
ider a
dditio
n of g
entam
icin i
f uns
table
In se
vere
seps
is: Ta
zocin
+/-
Gen
tamici
n
Cons
ider 7
-10
day c
ourse
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 +
/- te
icopla
nin
Discu
ss wi
th M
icrob
iolog
y tea
m as
soon
as
possi
ble
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
21
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
.
Refe
r to
Appe
ndix
5 a
t bac
k of
boo
klet
.
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
Refe
r to C
. diffi
cile a
lgorit
hm on
page
32.
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
22
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 500
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 26
- 27)
+ 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
. (Do
xycy
cline
is co
ntra
indica
ted
in pr
egna
ncy)
Cons
ider t
reati
ng pa
rtner.
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
23
Co
nditi
on
Antib
iotic
Co
mm
ents
Bone
and
Joint
Infe
ction
s
*Prop
hylax
is of
open
frac
ture -
se
e loc
al ort
hopa
edic
protoc
ols
avail
able
in su
rgica
l prop
hylax
is gu
idelin
es an
d ED
Dept.
*Diab
etic f
oot in
fectio
ns /
OM
cons
ult lo
cal/
natio
nal g
uideli
nes.
Skin
and
soft
tissu
e In
fecti
ons
Oste
omye
litis
/ Se
ptic
arth
ritis
Cellu
litis,
ery
sipela
s
Susp
ecte
d Se
vere
/Inv
asive
Gr
oup
A St
rep
Infe
ction
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 so
dium
fusid
ate as
abov
e. Se
vere
IgE m
ediat
ed re
actio
n/an
aphy
laxis
to pe
nicilli
n: Va
ncom
ycin
plus s
odium
fusid
ate
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
reacti
on/a
naph
ylaxis
): Ce
furox
ime 7
50mg
-1.5g
TDS
Seve
re Ig
E med
iated
reac
tion/
anap
hylax
isto
penic
illin:
Clind
amyc
in 1.
2g Q
DS IV
.(+
Vanc
omyc
in if
seve
re ce
lluliti
s)
Treat
as N
ecro
tising
fasc
itis,
see
belo
w
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
1.2g
QDS
+/- g
enta
mici
n.
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
10 da
ys m
inimu
m.
NOTE
: sev
ere
cellu
litis
shou
ld n
ot b
etre
ated
with
clar
ithro
myc
in).
If MR
SA su
spec
ted us
e van
comy
cin.
If Gr
oup A
Stre
p Inf
ectio
n con
firme
d, co
nside
r de-e
scalat
ion to
IV be
nzylp
enici
llin
plus c
linda
mycin
, foll
owing
discu
ssion
with
Mi
crobio
logist
.
Modif
y tre
atmen
t acco
rding
to M
icrob
iolog
y re
sults
and c
linica
l res
pons
e.
Penic
illin a
llerg
y: Do
xycy
cline
100
mg B
D PO
plu
s metr
onida
ziole
400m
g TDS
PO23
If se
vere
discu
ss wi
th m
icrob
iolog
y tea
m.G
uide
lines
for t
he e
mpi
ric u
se o
f ant
imic
robi
als
in a
dults
HSE
SE
Hos
pita
ls Ju
ly 2
016
Inde
x no
ASG
001
Dat
e of
App
rova
l Jul
y 20
16, R
evisi
on D
ate
July
201
7, R
evisi
on n
o 10
24
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) or
seve
re in
fecti
on su
spec
ted ad
d va
ncom
ycin
until
sens
itivitie
s con
firme
d. Tre
at fo
r 14
days
if pn
eumo
coccu
s. Tre
at fo
r 7 da
ys
if me
ningo
coccu
s. Se
vere
IgE m
ediat
ed re
actio
n/an
aphy
laxis
to pe
nicilli
n: ch
loram
phen
icol 1
g IV
QDS.
If im
muno
comp
romi
sed a
dd va
ncom
ycin
and
co-tr
imox
azole
.
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. (Se
e pag
e 42)
Requ
est H
SV PC
R on
CSF.
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 50
0mg
BD PO
for 1
0 da
ysSe
nd th
roat
swab
Penic
illin a
llerg
y: Cla
rithr
omyc
in 50
0mg B
DPO
for 5
-7 da
ys
Gui
delin
es fo
r the
em
piric
use
of a
ntim
icro
bial
s in
adu
lts H
SE S
E H
ospi
tals
July
201
6In
dex
no A
SG 0
01 D
ate
of A
ppro
val J
uly
2016
, Rev
ision
Dat
e Ju
ly 2
017,
Rev
ision
no
10
25
Da
y 1
: S
tart
Sm
art
...
...t
he
n F
oc
us (
Da
y 2
on
wa
rds)
nw
ard
s
Sta
rt S
ma
rt,
Th
en
Fo
cu
sA
ppen
dix
1:
Start
Sm
art
, Th
en F
ocus
Care
Bun
dle
.
26
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 2
7 fo
r dos
ing al
gorit
hm.
Endo
card
itis:
3mg/
kg on
ce da
ily
Note
exclu
sions
, plea
se di
scuss
with
Mi
crobio
logy T
eam.
and s
ee al
gorit
hm p2
7No
te: D
ivide
d dos
es pr
efered
to on
ce da
ily do
sing i
n the
follo
wing
cases
: •
Endo
card
itis ca
sed by
HAC
Ek or
ganis
ms•
Pros
thetic
Valve
Endo
card
itis•
Enter
ococ
cal E
ndoc
ardit
is(Li
st ma
y not
be ex
haus
tive -
discu
ss ca
se wi
th mi
crobio
logy t
eam)
.
Preg
nanc
y:
3-5m
g/kg
once
daily
Pleas
e disc
uss w
ith m
icrob
iolog
y tea
m if
need
ed an
d see
algo
rithm
p27.
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 27
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.
***C
learly
state
dose
, tim
e of d
ose a
nd tim
e of b
lood
samp
le co
llecti
on on
the r
eque
st fo
rm. *
**
Appen
dix
2: O
nce
daily
Am
inog
lyco
side
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
hlor
ide
0.9
% o
ver
30
-60
min
utes
.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
27Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016
Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
Adult Gentamicin Once Daily Dosing Guideline 1. Select patient appropriately
● Cautions : Endocarditis, pregnancy, renal replacement therapies, in Cystic Fibrosis & patients with severe burns. ● Consider patient factors associated with potential toxicity prior to prescribing Gentamicin e.g. underlying renal function, hearing
difficulty, and concurrent nephrotoxic drugs. ● Contraindicated in myasthenia gravis. ● Review need to continue Gentamicin beyond 7 days. Increased risk of nephrotoxicity beyond 7 days treatment. If to continue
rationale should be documented.
3. Check a trough level 16-18 hours after FIRST dose ● Monitor U&Es ensure patient is well hydrated and monitor creatinine as gentamicin is nephrotoxic. ● Ensure sample is labelled with the date & time of the last dose and the date & time level was taken. E.g. 4pm dosing=8 -10am level,
6pm dosing=10am-12noon level
4. Trough level Action <1µg/ml In range
Continue current regimen.
>1µg/ml Level is High
Check the time dose was given and sample taken. Was level taken at 16-18 hours after dose?
If trough level >1µg/ml and <2µg/ml and treatment still indicated then consider holding the dose until the level is <1µg/ml and reducing the dose by 1mg/kg. Discuss with Pharmacy if required.
If trough >2µg/ml and treatment still indicated seek advice from Pharmacy.
5. Repeat trough level when clinically indicated Creatinine normal Twice Weekly
Creatinine abnormal or deteriorating Daily or alternate days
2. Prescribe dose ● If weight> 120% IBW use obese dosing weight (ODW) to
calculate gentamicin dose ● Maximum dose 500mg daily ● If anuric (<500mls/day), treat as CrCl <10ml/min.
CrCl (ml/min) Dose
>80 5mg/kg
50-80 4mg/kg
30-50 3mg/kg
10-30 2mg/kg
<10 1-2mg/kg redose when level <1µg/ml
Calculating the dose
Weight used should be actual body weight (ABW), or for obese patients (Weight ≥ 120% IBW) an obese dosing weight (ODW) must be calculated.
For formula (see appendix 13 page 43)
Dose should never exceed 500mg daily
Adult Gentamicin Once Daily Dosing Guideline 1. Select patient appropriately
● Cautions : Endocarditis, pregnancy, renal replacement therapies, in Cystic Fibrosis & patients with severe burns. ● Consider patient factors associated with potential toxicity prior to prescribing Gentamicin e.g. underlying renal function, hearing
difficulty, and concurrent nephrotoxic drugs. ● Contraindicated in myasthenia gravis. ● Review need to continue Gentamicin beyond 7 days. Increased risk of nephrotoxicity beyond 7 days treatment. If to continue
rationale should be documented.
3. Check a trough level 16-18 hours after FIRST dose ● Monitor U&Es ensure patient is well hydrated and monitor creatinine as gentamicin is nephrotoxic. ● Ensure sample is labelled with the date & time of the last dose and the date & time level was taken. E.g. 4pm dosing=8 -10am level,
6pm dosing=10am-12noon level
4. Trough level Action <1µg/ml In range
Continue current regimen.
>1µg/ml Level is High
Check the time dose was given and sample taken. Was level taken at 16-18 hours after dose?
If trough level >1µg/ml and <2µg/ml and treatment still indicated then consider holding the dose until the level is <1µg/ml and reducing the dose by 1mg/kg. Discuss with Pharmacy if required.
If trough >2µg/ml and treatment still indicated seek advice from Pharmacy.
5. Repeat trough level when clinically indicated Creatinine normal Twice Weekly
Creatinine abnormal or deteriorating Daily or alternate days
2. Prescribe dose ● If weight> 120% IBW use obese dosing weight (ODW) to
calculate gentamicin dose ● Maximum dose 500mg daily ● If anuric (<500mls/day), treat as CrCl <10ml/min.
CrCl (ml/min) Dose
>80 5mg/kg
50-80 4mg/kg
30-50 3mg/kg
10-30 2mg/kg
<10 1-2mg/kg redose when level <1µg/ml
Calculating the dose
Weight used should be actual body weight (ABW), or for obese patients (Weight ≥ 120% IBW) an obese dosing weight (ODW) must be calculated.
For formula (see appendix 13 page 43)
Dose should never exceed 500mg daily
Adult Gentamicin Once Daily Dosing Guideline 1. Select patient appropriately
● Cautions : Endocarditis, pregnancy, renal replacement therapies, in Cystic Fibrosis & patients with severe burns. ● Consider patient factors associated with potential toxicity prior to prescribing Gentamicin e.g. underlying renal function, hearing
difficulty, and concurrent nephrotoxic drugs. ● Contraindicated in myasthenia gravis. ● Review need to continue Gentamicin beyond 7 days. Increased risk of nephrotoxicity beyond 7 days treatment. If to continue
rationale should be documented.
3. Check a trough level 16-18 hours after FIRST dose ● Monitor U&Es ensure patient is well hydrated and monitor creatinine as gentamicin is nephrotoxic. ● Ensure sample is labelled with the date & time of the last dose and the date & time level was taken. E.g. 4pm dosing=8 -10am level,
6pm dosing=10am-12noon level
4. Trough level Action <1µg/ml In range
Continue current regimen.
>1µg/ml Level is High
Check the time dose was given and sample taken. Was level taken at 16-18 hours after dose?
If trough level >1µg/ml and <2µg/ml and treatment still indicated then consider holding the dose until the level is <1µg/ml and reducing the dose by 1mg/kg. Discuss with Pharmacy if required.
If trough >2µg/ml and treatment still indicated seek advice from Pharmacy.
5. Repeat trough level when clinically indicated Creatinine normal Twice Weekly
Creatinine abnormal or deteriorating Daily or alternate days
2. Prescribe dose ● If weight> 120% IBW use obese dosing weight (ODW) to
calculate gentamicin dose ● Maximum dose 500mg daily ● If anuric (<500mls/day), treat as CrCl <10ml/min.
CrCl (ml/min) Dose
>80 5mg/kg
50-80 4mg/kg
30-50 3mg/kg
10-30 2mg/kg
<10 1-2mg/kg redose when level <1µg/ml
Calculating the dose
Weight used should be actual body weight (ABW), or for obese patients (Weight ≥ 120% IBW) an obese dosing weight (ODW) must be calculated.
For formula (see appendix 13 page 43)
Dose should never exceed 500mg daily
Twice weekly gentamicin trough level
Daily or alternate day gentamicin level
Adult Gentamicin Once Daily Dosing Guideline 1. Select patient appropriately
● Cautions : Endocarditis, pregnancy, renal replacement therapies, in Cystic Fibrosis & patients with severe burns. ● Consider patient factors associated with potential toxicity prior to prescribing Gentamicin e.g. underlying renal function, hearing
difficulty, and concurrent nephrotoxic drugs. ● Contraindicated in myasthenia gravis. ● Review need to continue Gentamicin beyond 7 days. Increased risk of nephrotoxicity beyond 7 days treatment. If to continue
rationale should be documented.
3. Check a trough level 16-18 hours after FIRST dose ● Monitor U&Es ensure patient is well hydrated and monitor creatinine as gentamicin is nephrotoxic. ● Ensure sample is labelled with the date & time of the last dose and the date & time level was taken. E.g. 4pm dosing=8 -10am level,
6pm dosing=10am-12noon level
4. Trough level Action <1µg/ml In range
Continue current regimen.
>1µg/ml Level is High
Check the time dose was given and sample taken. Was level taken at 16-18 hours after dose?
If trough level >1µg/ml and <2µg/ml and treatment still indicated then consider holding the dose until the level is <1µg/ml and reducing the dose by 1mg/kg. Discuss with Pharmacy if required.
If trough >2µg/ml and treatment still indicated seek advice from Pharmacy.
5. Repeat trough level when clinically indicated Creatinine normal Twice Weekly
Creatinine abnormal or deteriorating Daily or alternate days
2. Prescribe dose ● If weight> 120% IBW use obese dosing weight (ODW) to
calculate gentamicin dose ● Maximum dose 500mg daily ● If anuric (<500mls/day), treat as CrCl <10ml/min.
CrCl (ml/min) Dose
>80 5mg/kg
50-80 4mg/kg
30-50 3mg/kg
10-30 2mg/kg
<10 1-2mg/kg redose when level <1µg/ml
Calculating the dose
Weight used should be actual body weight (ABW), or for obese patients (Weight ≥ 120% IBW) an obese dosing weight (ODW) must be calculated.
For formula (see appendix 13 page 43)
Dose should never exceed 500mg daily
Adult Gentamicin Once Daily Dosing Guideline
28
App
endi
x 3
: Am
inog
lyco
side
s –
Am
ikac
in d
osin
g gu
idel
ines
Once
dai
ly d
osing
Dosin
g Sc
hedu
leM
onito
ring
and
Leve
lsCo
mm
ents
Refe
r to
Algo
rithm
pa
ge 2
9
lM
onito
r U&E
s ens
ure
patie
nt is
well
hyd
rate
d an
d m
onito
r cre
atini
ne a
s am
ikac
in is
neph
roto
xic.
lT
ROUG
H (i.
e. P
re-D
ose)
leve
ls re
quire
d. N
o ne
ed fo
r Pea
k lev
els.
lF
irst T
ROUG
H (P
re-d
ose)
leve
l to
be ta
ken
just
prio
r to
the
seco
nd.18
lTa
rget
TRO
UGH
(Pre
-dos
e) le
vel ≤
5mg/
L15
lE
nsur
e sa
mpl
e is
labe
lled
with
the
date
& ti
me
of th
e la
st d
ose
and
the
date
& ti
me
level
was
take
n.
lA
mik
acin
is a
rest
ricte
d an
timicr
obia
l and
shou
ld o
nly b
e pr
escri
bed
for t
he
treat
men
t of i
nfec
tions
due
to g
enta
mici
n re
sista
nt G
ram
neg
ativ
e ba
cilli
or if
re
com
men
ded
by a
cons
ultan
t micr
obio
logi
stlS
tand
ard
Once
dai
ly re
gim
en is
not
suita
ble
in en
doca
rditi
s15, c
ystic
fibr
osis19
, as
cities
19, m
ajor
bur
ns19
, feb
rile
neut
rope
nia15
, men
ingiti
s15, t
uber
culo
sis, o
r pr
egna
ncy15
. Use
mult
iple
daily
dos
ing se
e pa
ge 2
9.lC
onsid
er re
nal f
uncti
on, h
ydra
tion
stat
us a
nd co
ncom
itant
nep
hrot
oxic
med
icine
slT
hera
peut
ic Dr
ug M
onito
ring
is ne
cess
ary
to p
reve
nt to
xicit
y no
tabl
y ne
phro
toxi
city
& ot
otox
icity
.lR
isk o
f oto
toxi
city
incre
ases
with
hig
her c
umula
tive
dose
s and
long
er tr
eatm
ent
cour
ses.
lC
ontra
-indi
cate
d in
mya
sthe
nia g
ravi
s.15
Mult
iple
daily
dos
ingDo
sing
Sche
dule
Mon
itorin
g an
d Le
vels
Com
men
tsRe
fer t
o Al
gorit
hm
pg 2
9
lM
onito
r U&E
s ens
ure
patie
nt is
well
hyd
rate
d an
d m
onito
r cre
atini
ne a
s am
ikac
in is
neph
roto
xic.
lT
ROUG
H (i.
e. P
re-D
ose)
leve
ls re
quire
d. Ta
ke
TROU
GH le
vel i
mm
edia
tely
pre
-dos
e.18
Tar
get
Trou
gh Le
vel ≤
10m
g/L
lP
EAK
levels
requ
ired.
Take
PEA
K lev
el on
e ho
ur
post
dos
e. Ta
rget
Pea
k Le
vel ≤
30m
g/L18
lIn
itial
ly ta
ke P
EAK
& TR
OUGH
leve
ls ar
ound
th
e th
ird/f
ourth
dos
e. T
hen
take
TRO
UGH
(Pre
-dos
e) le
vels
ever
y 48
hrs
or m
ore
if re
nal
func
tion
is un
stab
le/im
paire
d. M
onito
r Pea
k lev
els O
nce
wee
kly.
lE
nsur
e sa
mpl
e is
labe
lled
with
the
date
& ti
me
of th
e la
st d
ose
and
the
date
& ti
me
level
was
take
n.
lA
mik
acin
is a
rest
ricte
d an
timicr
obia
l and
shou
ld o
nly b
e pr
escri
bed
for t
he
treat
men
t of i
nfec
tions
due
to g
enta
mici
n re
sista
nt G
ram
neg
ativ
e ba
cilli
or if
re
com
men
ded
by a
cons
ultan
t micr
obio
logi
stlM
ultip
le Da
ily D
osing
dai
ly re
gim
en is
to b
e us
ed fo
r ind
icatio
ns o
f end
ocar
ditis
, cy
stic
fibro
sis, a
sciti
es, m
ajor
bur
ns, f
ebril
e ne
utro
penia
, men
ingiti
s or p
regn
ancy
. lT
hera
peut
ic Dr
ug M
onito
ring
is ne
cess
ary
to p
reve
nt to
xicit
y no
tabl
y ne
phro
toxi
city
& ot
otox
icity
.lR
isk o
f oto
toxi
city
incre
ases
with
hig
her c
umula
tive
dose
s and
long
er tr
eatm
ent
cour
ses.
lC
ontra
-indi
cate
d in
mya
sthe
nia g
ravi
s.15
29
App
endi
x 3
: Am
inog
lyco
side
s –
Am
ikac
in d
osin
g gu
idel
ines
Once
dai
ly d
osing
Dosin
g Sc
hedu
leM
onito
ring
and
Leve
lsCo
mm
ents
Refe
r to
Algo
rithm
pa
ge 2
9
lM
onito
r U&E
s ens
ure
patie
nt is
well
hyd
rate
d an
d m
onito
r cre
atini
ne a
s am
ikac
in is
neph
roto
xic.
lT
ROUG
H (i.
e. P
re-D
ose)
leve
ls re
quire
d. N
o ne
ed fo
r Pea
k lev
els.
lF
irst T
ROUG
H (P
re-d
ose)
leve
l to
be ta
ken
just
prio
r to
the
seco
nd.18
lTa
rget
TRO
UGH
(Pre
-dos
e) le
vel ≤
5mg/
L15
lE
nsur
e sa
mpl
e is
labe
lled
with
the
date
& ti
me
of th
e la
st d
ose
and
the
date
& ti
me
level
was
take
n.
lA
mik
acin
is a
rest
ricte
d an
timicr
obia
l and
shou
ld o
nly b
e pr
escri
bed
for t
he
treat
men
t of i
nfec
tions
due
to g
enta
mici
n re
sista
nt G
ram
neg
ativ
e ba
cilli
or if
re
com
men
ded
by a
cons
ultan
t micr
obio
logi
stlS
tand
ard
Once
dai
ly re
gim
en is
not
suita
ble
in en
doca
rditi
s15, c
ystic
fibr
osis19
, as
cities
19, m
ajor
bur
ns19
, feb
rile
neut
rope
nia15
, men
ingiti
s15, t
uber
culo
sis, o
r pr
egna
ncy15
. Use
mult
iple
daily
dos
ing se
e pa
ge 2
9.lC
onsid
er re
nal f
uncti
on, h
ydra
tion
stat
us a
nd co
ncom
itant
nep
hrot
oxic
med
icine
slT
hera
peut
ic Dr
ug M
onito
ring
is ne
cess
ary
to p
reve
nt to
xicit
y no
tabl
y ne
phro
toxi
city
& ot
otox
icity
.lR
isk o
f oto
toxi
city
incre
ases
with
hig
her c
umula
tive
dose
s and
long
er tr
eatm
ent
cour
ses.
lC
ontra
-indi
cate
d in
mya
sthe
nia g
ravi
s.15
Mult
iple
daily
dos
ingDo
sing
Sche
dule
Mon
itorin
g an
d Le
vels
Com
men
tsRe
fer t
o Al
gorit
hm
pg 2
9
lM
onito
r U&E
s ens
ure
patie
nt is
well
hyd
rate
d an
d m
onito
r cre
atini
ne a
s am
ikac
in is
neph
roto
xic.
lT
ROUG
H (i.
e. P
re-D
ose)
leve
ls re
quire
d. Ta
ke
TROU
GH le
vel i
mm
edia
tely
pre
-dos
e.18
Tar
get
Trou
gh Le
vel ≤
10m
g/L
lP
EAK
levels
requ
ired.
Take
PEA
K lev
el on
e ho
ur
post
dos
e. Ta
rget
Pea
k Le
vel ≤
30m
g/L18
lIn
itial
ly ta
ke P
EAK
& TR
OUGH
leve
ls ar
ound
th
e th
ird/f
ourth
dos
e. T
hen
take
TRO
UGH
(Pre
-dos
e) le
vels
ever
y 48
hrs
or m
ore
if re
nal
func
tion
is un
stab
le/im
paire
d. M
onito
r Pea
k lev
els O
nce
wee
kly.
lE
nsur
e sa
mpl
e is
labe
lled
with
the
date
& ti
me
of th
e la
st d
ose
and
the
date
& ti
me
level
was
take
n.
lA
mik
acin
is a
rest
ricte
d an
timicr
obia
l and
shou
ld o
nly b
e pr
escri
bed
for t
he
treat
men
t of i
nfec
tions
due
to g
enta
mici
n re
sista
nt G
ram
neg
ativ
e ba
cilli
or if
re
com
men
ded
by a
cons
ultan
t micr
obio
logi
stlM
ultip
le Da
ily D
osing
dai
ly re
gim
en is
to b
e us
ed fo
r ind
icatio
ns o
f end
ocar
ditis
, cy
stic
fibro
sis, a
sciti
es, m
ajor
bur
ns, f
ebril
e ne
utro
penia
, men
ingiti
s or p
regn
ancy
. lT
hera
peut
ic Dr
ug M
onito
ring
is ne
cess
ary
to p
reve
nt to
xicit
y no
tabl
y ne
phro
toxi
city
& ot
otox
icity
.lR
isk o
f oto
toxi
city
incre
ases
with
hig
her c
umula
tive
dose
s and
long
er tr
eatm
ent
cour
ses.
lC
ontra
-indi
cate
d in
mya
sthe
nia g
ravi
s.15
Adult Amikacin Dosing Guideline
1. Select patient appropriately Consider once daily dosing (except for indications for multiple daily dosing on page 28).
2. Prescribe dose based on Patient’s – Weight, Height, BMI & Renal Function CHECK & DOCUMENT: Weight, Height, Renal Function (CrCl) before prescribing dose Maximum dose 1.5g daily (Maximum cumulative dose 15g15 ) If weight > Ideal Body Weight (IBW), Dose is based on IBW.
See indications p28.
If weight is < IBW use actual body weight Obese patients (weight >120% IBW), use ODW.
For formula for weight calculation see appendix 11, page 43-44
MULTIPLE DAILY DOSING 17
Renal Function CrCl ml/min
Dose
> 50ml/min 7.5mg/kg every 12 hours 20-50 ml/min 5-6mg/kg every 12 hours
10-20ml/min 3-4mg/kg every 24 hours <10ml/min 2mg/kg every 24-48 hours
ONCE DAILY DOSING 16
Renal Function CrCl ml/min
Dose
> 80ml/min
60-80 ml/min
40-60 ml/min
30-40 ml/min
20-30ml/min
< 20 ml/min
3. Monitor Renal function and Carryout Therapeutic Drug Monitoring
ONCE DAILY DOSING
4. Take Trough level then give the next dose (provided patient is not at risk of nephrotoxicity). Check the trough level result before giving the SECOND dose. (See page 28 for guidance on monitoring and levels) Trough level Action ≤ 5mg/L15 In range
● Continue current regimen. Provided renal function is stable. Monitor level every 3-5 days.
> 5mg/L15 Level is High
●Check when level was taken – level taken <18hrs post dose are not true trough levels. ● If it is a true trough level then omit next dose, re-assay in 24 hrs. & check U&Es ● Re-dose if clinically indicated when levels fall ≤5mg/L but extend dosing interval accordingly for subsequent doses depending on the creatinine clearance - discuss appropriate reduced dose with pharmacist.
MULTIPLE DAILY DOSING
4. Interpretation of Therapeutic Drug Monitoring Troughs & Peaks (See page 28 for guidance on monitoring and levels) Trough level Action ≤ 10mg/L15 In range
Continue current dose regimen. Provided renal function is stable and continued administration is required, monitor levels twice weekly.
> 10mg/L15 Level is High
Ensure the level was taken at the correct time. If a true pre-dose level omit any further doses. Re-check renal function and review need for further amikacin treatment. If further advice is needed contact pharmacy.
Peak level Action ≤ 30mg/L15 In range
Continue current regimen. Provided dose & renal function is stable and continued administration is required, monitor peak levels once weekly.
> 30mg/L15 Level is High
Check level taken at correct time. Contact pharmacy for advice on further management.
15mg/kg daily12mg/kg daily
7.5mg/kg daily4mg/kg daily
7.5mg/kg every 48 hours Multiple Daily Dosing Recommended
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
30
Adult VANCOMYCIN Dosing Guideline
1. Select patient appropriately ■ Renal
Renal
& ototoxicity has been associated with use of vancomycin. ■ Monitoring of serum levels is a necessity. ■ Administer at a rate not greater than 10mg/min.
2. Prescribe dose
Actual body weight is used to calculate all doses unless weight >120% IBW use obese dosing weight-
see
calculations as per Appendix 13page 43-44.
CrCl Dose (Round to nearest 50mg)
> 60ml/min 15mg/kg BD
30 – 60 ml/min 15mg/kg OD
15 – 30 ml/min 15mg/kg every 48hrs
< 15 ml/min or dialysis
15mg/kg day 1. Only re-dose at 15mg/kg when trough level in target range. Hold dose until level available
■ Maximum Single Dose 2g ■ If anuric, output<500mls/day, treat as CrCl < 15ml/min
3. Take FIRST trough level BEFORE 4th dose. Trough must be measured PRE-DOSE (or within one hour prior to administering dose)
Doses are NOT to be held whilst awaiting levels unless renal function deteriorating or speci�ically advised
4. Ascertain target level. Standard target level is 10-15mg/L but if patient has a serious infection such as endocarditis, osteomyelitis, bloodstream infection, meningitis or hospital-acquired pneumonia caused by S.aureus, target level is 15-20mg/L.
5. Check trough level result and adjust dose accordingly Target level 10-15mg/L Target Level 15-20mg/L Level (mg/L)
Dose alteration Recheck pre-dose level Level (mg/L)
Dose alteration Recheck pre-dose level
<5# Increase each dose by 500mg
After adjusted dose given and before following morning dose*
<10# Increase each dose by 500mg
After adjusted dose given and before following morning dose*
5-10 Increase each dose by 250mg
After adjusted dose given and before following morning dose*
10-15 Increase each dose by 250mg
After adjusted dose given and before following morning dose*
10-15 Maintain dosing regimen
Twice weekly, providing renal function is stable*
15-20 Maintain dosing regimen
Twice weekly providing renal function is stable*
15-20 Reduce each dose by 250mg
After adjusted dose given and before following morning dose*
20-25 Reduce each dose by 250mg
After adjusted dose given and before following morning dose*
>20 Omit next dose and decrease each dose by 500mg
After adjusted dose given and before following morning dose*
>25 Omit next dose and decrease each dose by 500mg
After adjusted dose given and before following morning dose*
* Doses are NOT to be held whilst awaiting levels unless renal function is deteriorating or speci�ically advised # If persistently sub-therapeutic levels, consult pharmacy or microbiology for advice
6. Check serum creatinine regularly ■ Ensure patient well hydrated. ■ If renal function stable (& level in target range), twice weekly levels are suf�icient ■ If renal function unstable, check trough level more frequently (e.g. daily or alternate days)
Initial Dose: Prescribe initial loading dose of 25mg/kgMaximum single dose 2g
Maintenance Dose: see table below
Va
ncom
ycin
Dosa
ge S
ched
ule
Leve
ls Co
mm
ents
Refe
r to
dosin
g al
gorit
hm p
age
31.
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
. A
load
ing d
ose
of 2
5mg/
kg w
ill
facil
itate
rapi
d at
tainm
ent o
f ta
rget
trou
gh se
rum
van
com
ycin
conc
entra
tion.
Espe
cially
impo
rtant
in
com
plica
ed in
fecti
ons s
uch
as:
1. B
acter
aemi
a2.
Endo
card
itis3.
Oste
omye
litis
4. M
ening
itis5.
Hos
pital
Acqu
ired I
nfec
tions
caus
ed by
Sta
ph au
reus
Com
men
tsRe
nal im
pairm
ent:
If tei
copla
nin is
to be
used
, the
full d
ose
is giv
en fo
r the
first
4 da
ys. T
here
after
ex
tende
d dos
ing in
terva
ls ar
e req
uired
.(se
e also
appe
ndix
10 pa
ge 4
2).
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
.
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.
App
endi
x 4
: Gly
cope
ptid
es: V
anco
myc
in &
Tei
copla
nin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
31
Adult VANCOMYCIN Dosing Guideline
1. Select patient appropriately ■ Renal
Renal
& ototoxicity has been associated with use of vancomycin. ■ Monitoring of serum levels is a necessity. ■ Administer at a rate not greater than 10mg/min.
2. Prescribe dose
Actual body weight is used to calculate all doses unless weight >120% IBW use obese dosing weight-
see
calculations as per Appendix 13page 43-44.
CrCl Dose (Round to nearest 50mg)
> 60ml/min 15mg/kg BD
30 – 60 ml/min 15mg/kg OD
15 – 30 ml/min 15mg/kg every 48hrs
< 15 ml/min or dialysis
15mg/kg day 1. Only re-dose at 15mg/kg when trough level in target range. Hold dose until level available
■ Maximum Single Dose 2g ■ If anuric, output<500mls/day, treat as CrCl < 15ml/min
3. Take FIRST trough level BEFORE 4th dose. Trough must be measured PRE-DOSE (or within one hour prior to administering dose)
Doses are NOT to be held whilst awaiting levels unless renal function deteriorating or speci�ically advised
4. Ascertain target level. Standard target level is 10-15mg/L but if patient has a serious infection such as endocarditis, osteomyelitis, bloodstream infection, meningitis or hospital-acquired pneumonia caused by S.aureus, target level is 15-20mg/L.
5. Check trough level result and adjust dose accordingly Target level 10-15mg/L Target Level 15-20mg/L Level (mg/L)
Dose alteration Recheck pre-dose level Level (mg/L)
Dose alteration Recheck pre-dose level
<5# Increase each dose by 500mg
After adjusted dose given and before following morning dose*
<10# Increase each dose by 500mg
After adjusted dose given and before following morning dose*
5-10 Increase each dose by 250mg
After adjusted dose given and before following morning dose*
10-15 Increase each dose by 250mg
After adjusted dose given and before following morning dose*
10-15 Maintain dosing regimen
Twice weekly, providing renal function is stable*
15-20 Maintain dosing regimen
Twice weekly providing renal function is stable*
15-20 Reduce each dose by 250mg
After adjusted dose given and before following morning dose*
20-25 Reduce each dose by 250mg
After adjusted dose given and before following morning dose*
>20 Omit next dose and decrease each dose by 500mg
After adjusted dose given and before following morning dose*
>25 Omit next dose and decrease each dose by 500mg
After adjusted dose given and before following morning dose*
* Doses are NOT to be held whilst awaiting levels unless renal function is deteriorating or speci�ically advised # If persistently sub-therapeutic levels, consult pharmacy or microbiology for advice
6. Check serum creatinine regularly ■ Ensure patient well hydrated. ■ If renal function stable (& level in target range), twice weekly levels are suf�icient ■ If renal function unstable, check trough level more frequently (e.g. daily or alternate days)
Initial Dose: Prescribe initial loading dose of 25mg/kgMaximum single dose 2g
Maintenance Dose: see table below
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
contact pharmacy for advice
32
32 Updated CDI guidelines February 2013
Figure R2: CDI disease severity stratification and general and specific treatment measures for initial episode of CDI and first recurrence.(29)
Please refer to BNF for children or local paediatric formulary for doses of metronidazole and vancomycin for paediatric patients.
INITIAL EPISODE OF CDI OR FIRST RECURRENCE General Measures:
• Adequate replacement of fluid and electrolytes • Immediately discontinue unnecessary antimicrobial therapy • Avoid antimotility medications • Review other risk factors for CDI • Review proton pump inhibitor use • Appropriate infection prevention and control to include patient isolation with Contact Precautions and
appropriate hand washing.
Mild to Moderate CDI: • No features of severe CDI
• Oral or nasogastric metronidazole 400 mg TDS for 10 to 14 days. (Grade A)
• Inability to take oral medication: intravenous (IV) metronidazole 500mg TDS for 10 to 14 days. (Grade D)
• Metronidazole intolerance or contraindication: oral vancomycin 125mg QDS for 10 to 14 days. (Grade A)
• * Oral fidaxomicin 200mg BD for 10 days may be an alternative to metronidazole(Grade C/D) or vancomycin (Grade A) in patients aged 16 yrs and older but only following discussion with a clinical microbiologist or specialist ID consultant.
• Monitor closely for deterioration/progression to severe CDI
Severe CDI:(Suggested by any of the following) • Clinical: fever, rigors, abdominal pain • Laboratory: Leucocytosis of ≥15,000
cells/µL , or rise in serum creatinine of ≥50% above baseline or serum creatinine >133 µmol/L).
• Endoscopic findings: pseudo membranous colitis
• Early surgical opinion • Oral vancomycin 125 mg, QDS
for 10 to 14 days. (Grade A) • *Oral fidaxomicin 200mg BD
for 10 days may be an alternative to vancomycin (Grade A) in patients aged 16 yrs and older but only following discussion with a clinical microbiologist or specialist infectious diseases consultant.
Severe, complicated CDI:Severe disease with:
• Hypotension • Shock • Rising serum lactic acid levels • Ileus • Mega colon
• Early surgical opinion • Vancomycin 500 mg, oral or
nasogastric QDS and metronidazole 500mg, IV TDS (Grade D)
• Consider Intracolonic vancomycin 500 mg, four to six times daily if ileus present or suspected (Grade D)
Adapted From Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland Update of 2008 Guidance HPSC 2013
Appendix 5: Treatment of Clostridium difficile Infection
13
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
33
34 Updated CDI guidelines February 2013
7. How do you manage second and subsequent recurrences and what do you do if a
patient keeps getting recurrences? • Management of second and subsequent recurrences of CDI is summarised in Figure R3. • Consider supervised trial of anti‐motility agents alone if post‐infective irritable bowel
syndrome is suspected after more than 20 days of anti‐C. difficile treatment (only if patient has a normal white cell count and no abdominal symptoms or signs of severe CDI). (Grade D)
Figure R3: Management of Multiple Recurrences of CDI
First episode of recurrent CDI
Severity assessment, general measures and specific anti‐CDI therapy as outlined on page 32
• Review all anti‐microbial therapy and other medications. Ensure adequate fluid and electrolytes and review nutritional status. (Grade D)
• Contact clinical microbiologist or specialist infectious diseases consultant expert for advice
• Consider the following options after expert advice as above: • Oral Vancomycin tapering/pulse therapy (Grade D):
o 125mg 6 hourly for 7 days o 125 mg 12 hourly for 7 days o 125 mg daily for 7 days o 125 mg every other day for 7 days o 125 mg every 3 days for 7 days
or • Oral Fidaxomicin 200mg BD for 10 days (Grade D) or • Oral Vancomycin 125mg QDS for 10 days followed by a chaser of oral
rifaximin 400mg TDS for 20 days (Grade B) or • Intravenous immunoglobulin therapy 150‐400mg/kg per day for 1 to
3 doses (Grade D) or • Faecal microbiota transplantation (Grade A)
Second and subsequent episodes of recurrent CDI
Adapted From Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland Update of 2008 Guidance HPSC 2013
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
34
ANTIMICROBIALS WITH GOOD ORAL BIOAVAILABILITY
*Sanford Guide 2014** Martindale 33rd
edition***Sanford Guide 2014 and Martindale 33rd
edition
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.
Antimicrobial Oral BioavailabilityCiprofloxacin 70-80%***Clindamycin 90%*Sodium Fusidate 91%(tablets)*Fluconazole 90%*Levofloxacin 99%*Linezolid 100%*Metronidazole 99%**
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
Appendix 6: IV to PO Switch
35
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
Le
voflo
xacin
500
mg -
24hr
/12h
r Le
voflo
xacin
500
mg -
24hr
/12h
rCe
furo
xime 7
50mg
- 1.
5 g T
DS 8
hr
Co-a
moxic
lav 6
25mg
8 hr
In Pe
nicilli
n Alle
rgy d
iscus
s with
Micr
obiol
ogist
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
36
Appendix 7: Relative Costs of Antimicrobials*
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
Relative Costs of AntimicrobialsCOST 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, Doxycycline PO, Levofloxacin PO
€10-€40 Clindamycin PO, Fusidic acid PO, Oseltamivir PO, Amoxicillin IV, Metronidazole IV, Co-amoxiclav IV, Cefuroxime IV,Ciprofloxacin IV, Fluconazole PO,Levofloxacin IV, Fluconazole IV
€40-€60 Gentamicin IV, Benzypenicillin IV, Piperacillin-Tazobactam IV, Vancomycin IV
€100-€300 Colistin IV, Meropenem IV, Clarithromycin IV, Rifampicin IV, Amikacin IV, Ceftriaxone IV, Aciclovir IV, Aztreonam IV, Cefazolin IV (Unlicensed), Fosfomycin PO
€300-€500 Clindamycin IV, Ertapenem IV, Linezolid PO & IV€500-€1000 Ceftazidime IV, , Ceftaroline IV, Fosfomycin IV,
Tigecycline IV
€1000-€3000
Daptomycin IV, Teicoplanin IV, Fidaxomicin PO, Anidulafungin IV, Voriconazole PO
>€3000 Voriconazole IV, Amphotercin IV, Caspofungin IV
37
Appendix 8: Tips on Clinical Assessment of Patients Following Notification of
Positive Blood Culture and Gram Stain.
Gram Positive Cocci (GPC)Perhaps the most common gram stain result phoned during the working day or after hours.Potential GPC organisms (most common):Staphylococci (Staphylococcus aureus (MSSA or MRSA) or Coagulase Negative Staphylococci)Staphylococci often have an appearance of cells in groups or clusters on gram.Streptococci (Including Group A streptococci or other haemolytic streptococci e,g Group B/C/G, Enterococci (including Ent Faecalis / Ent faecium / VRE if either resistant to vancomycin) Streptococcus pneumoniae, (pneumococcus), Streptococcus viridans.Streptococci often have an appearance of cells in pairs or chains on gramRisk assessment The key is to review the patient carefully for signs and symptoms of sepsis / bacteraemia. Carry out a NEWS score and follow the Sepsis Six protocol if clinically indicated. Bear in mind that the gram stain result may reflect a causative organism of life threatening sepsis ( e,g MSSA, MRSA, Group A Strep, Streptococcus pneumoniae, Enterococcus spp ) or a skin contaminant (e.g Coag Neg Staph / Strep viridans) , therefore careful clinical risk assessment is paramount. Note it is important not to dismiss potential skin contaminants such as Coagulase Neg Staph / Strep viridans if endocarditis / intravascular catheter or prosthetic device infection suspected. Empiric Antibiotic CoverThis should be guided by the gram stain appearance and likely significance / pathogen based on the clinical risk assessment. Consult the current empiric antimicrobial guideline document for advice on empiric cover in the relevant section. Check previous microbiology results and for a history of MRSA colonisation / infection. If the potential pathogen appears likely from the likely source of sepsis ensure patient is on appropriate antimicrobial therapy for that source and pathogen ( e.g Group A Strep in severe soft tissue infection / Strep pneumoniae in CAP).If systemic sepsis suspected, and source and potential pathogen unclear - glycopeptides cover most gram positive organisms and a stat dose of vancomycin is a reasonable option to cover the patient pending the culture result of ID and sensitivity. It is critically important however that this step is taken only if clinical indication of sepsis or significant infection and that the antimicrobial treatment is later reviewed with the culture ID and sensitivity and assessed re need to continue / stop / change therapy.If the patient is clinically well following a thorough clinical review and contamination is suspected – a watch- and-observe approach is reasonable pending ID and sensitivity on culture. Ensure there is a trigger for a repeat review and initiation of empiric antimicrobial therapy if the patient develops new signs/symptoms.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
Relative Costs of AntimicrobialsCOST 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, Doxycycline PO, Levofloxacin PO
€10-€40 Clindamycin PO, Fusidic acid PO, Oseltamivir PO, Amoxicillin IV, Metronidazole IV, Co-amoxiclav IV, Cefuroxime IV,Ciprofloxacin IV, Fluconazole PO,Levofloxacin IV, Fluconazole IV
€40-€60 Gentamicin IV, Benzypenicillin IV, Piperacillin-Tazobactam IV, Vancomycin IV
€100-€300 Colistin IV, Meropenem IV, Clarithromycin IV, Rifampicin IV, Amikacin IV, Ceftriaxone IV, Aciclovir IV, Aztreonam IV, Cefazolin IV (Unlicensed), Fosfomycin PO
€300-€500 Clindamycin IV, Ertapenem IV, Linezolid PO & IV€500-€1000 Ceftazidime IV, , Ceftaroline IV, Fosfomycin IV,
Tigecycline IV
€1000-€3000
Daptomycin IV, Teicoplanin IV, Fidaxomicin PO, Anidulafungin IV, Voriconazole PO
>€3000 Voriconazole IV, Amphotercin IV, Caspofungin IV
38
Gram Negative Bacilli (GNB)
Gram negative bacilli on gram of blood culture represents presumptive gram negative septicaemia and the need for urgent review and prompt antibiotic treatment pending confirmation of ID.
Potential GNB organisms (most common):Enterobacteriaciae including E-coli, Klebsiella,Enterobacter spp, Pseudomonas, Acinetobacter spp, gram negative anaerobes including bacteroides (less common)Note that MDRO (Multi-Drug Resistant Organism) including ESBL E-coli/Klebisella, CRE E coli/Klebsiella, MDR Pseudomonas / Acinetobacter are included in this category
Risk assessment The key is to review the patient carefully for signs and symptoms of sepsis / bacteraemia. Carry out a NEWS score and follow the Sepsis Six protocol if clinically indicated. Bear in mind that the gram stain result of GNB may reflect a causative organism of life threatening sepsis and may harbour antibiotic resistance mechanisms. Ensure Sepsis Protocols are followed as clinically appropriate.In a very small number of cases GNB on blood culture may turn out to be contaminants (e.g some Acinetobacter / environmental GNBs) but the vast majority are clinically significant and often pathogens of life-threatening sepsis, warranting immediate appropriate antibiotic therapy and source control.
Empiric Antibiotic CoverGram negative sepsis requires urgent review and appropriate empiric antibiotic therapy.Consult this document for advice on empiric cover in the relevant section. If the potential pathogen appears likely from the likely source of sepsis ensure patient is on appropriate antimicrobial therapy for that source and pathogen. If source unclear – see section on Septicaemia / Systemic Sepsis – Unknown source on P.6 of this guideline.
Gram Negative Cocci (GNC)
Gram negative cocci on gram of blood culture represents presumptive Meningococcal Septicaemia and is a medical emergency warranting urgent senior clinical review, supportive therapy and rapid administration of appropriate empiric antimicrobials pending confirmation of ID. Notify Public Health.
The key is to review the patient urgently for signs and symptoms of meningococcal sepsis. The patient may already be on appropriate empiric therapy following the initial clinical assessment if meningococcal sepsis was suspected. Carry out a NEWS score and follow the Sepsis Six protocol if clinically indicated. Ensure Meningococcal Sepsis Protocols are followed and that the patient is on the appropriate antimicrobials and doses.See relevant section in this guideline.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
39
Gram Positive Bacilli (GPB)
Potential GPB organisms later confirmed by culture:“Diphtheroid” bacilli or CoryneformsProprionibacteriaBacillus speciesListeria monocytogenes/sppAnaerobic GPB including Clostridium perfringens and other Clostridia species
Risk assessment The key is to review the patient carefully for signs and symptoms of sepsis / bacteraemia. Carry out a NEWS score and follow the Sepsis Six protocol if clinically indicated. Bear in mind that the gram stain result may reflect a causative organism of life threatening sepsis ( e,g Listeria / Clostridia species) or more frequently, a skin contaminant (e,g Diphtheroid bacilli or Bacillus species), therefore careful clinical risk assessment is paramount. It is important not to dismiss potential skin contaminants such as Diphtheroid bacilli / Bacillus species if endocarditis / intravascular catheter or prosthetic device infection suspected, or if the more uncommon conditions such as Diphtheria / Bacillus anthracis / Bacillus cereus infection suspected on clinical grounds.
Empiric Antibiotic CoverThis should be guided by the gram stain appearance and likely significance / pathogen based on the clinical risk assessment. If Listeria bacteraemia / sepsis suspected – Amoxicillin +/- Gentamicin (Penicillin allergy - use Vancomycin)If Clostridial bacteraemia / sepsis suspected (e.g in setting of faecal peritonitis / severe wound infection etc) – a broad – spectrum penicillin such as co-amoxiclav / piperacillin – tazobactam + metronidazole (in penicillin allergy discuss with microbiology team).If systemic sepsis suspected, and source unclear - glycopeptides cover most gram positive organisms and a reasonable option to cover the patient pending ID and sensitivity and follow up with culture and review of antimicrobial therapy.However if the patient is clinically well following a thorough clinical review and contamination is suspected, – a watch-and-observe approach is reasonable pending ID and sensitivity on culture. Bear in mind that the patient may already be on appropriate antibiotic regimen for their condition. Ensure there is a trigger for a repeat review and initiation of empiric antimicrobial therapy if the patient develops new signs/symptoms.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
40
Yeasts on gram stain
Yeasts on gram stain should be considered as significant and suggestive of candidaemia ( candida blood stream infection) pending full clinical review and subsequent species identification.Assess the patient for signs and symptoms of candidaemia, carry out a NEWS score and review previous microbiology results for history of candida colonisation.
Review with regards to potential source(s) including intravenous catheters.
Empiric antifungal cover Start an echinocandin such as anidulafungin 200mg stat IV followed by 100mg OD IV pending subsequent identification of the candida species and antifungal sensitivity testing. Liaise with clinical microbiology team regarding follow up and assessment for potential de-escalation to fluconazole as part of the clinical review the following day, and for advice on ongoing management such as source control and optimisation of antifungal therapy based on antifungal sensitivity testing and clinical response.
Note on Appendix 8:Please note that this guide is not comprehensive of all potential pathogens and scenarios for positive blood cultures. It is a simply a guide to aid the attending doctor when assessing the clinical significance and need for urgent action on receipt of a new blood culture gram stain result (verbal / electronic).All empiric therapy should be modified according to definitive ID and sensitivity testing, clinical response and senior consultation.
Each individual case should be taken on its own merits and the clinical assessment of the patient and actions, including prescribing of empiric antimicrobial therapy for newly positive blood cultures remains the responsibility of the attending clinician.
41
Appendix 9: Guidelines for Consultation with the Clinical Microbiology Advisory Team (C-MAT)
University Hospital WaterfordThe On-Duty Clinical Microbiology Advisory Team (C-MAT) can be contacted on the contact numbers on page 40 (9.30 - 5.30 Monday to Friday). A consultant out-of-hours-service is available for urgent clinical advice outside of these hours. Prior to contacting the team please have the following 3 actions completed:1. Review the Guidelines for Empiric Use of Antimicrobials in Adults 2014 – many queries including empiric
therapy by condition, treatment algorithms and therapeutic drug monitoring can be answered here.2. Ensure the patients’ previous microbiology results have been reviewed and summarised and available for
the consultation.3. Provide the C-MAT team member with an ISBAR summary – please see below
C-MAT Consultation Modified ISBAR
Identify1.Yourself, 2. Patient, Name, MRN, DOB, Ward
SituationSummarise main issues related to sepsis / infectionInclude other relevant key issues in presenting complaint
Backgound LOS in hospitalLead up to this point – course in hospital, procedures done and dates, relevant test resultsCurrent antimicrobial therapy
AssessmentOutline relevant details of your clinical assessment– general impression, signs and symptoms, temp, BP, NEWS score etcLaboratory findings – e.g WCC, CRP, Lactate, Renal fx , Liver fx, Other as relevantImaging results if available and relevant ( Echo, CT, MRI, Bone Scan, Other )Results of other relevant investigations available / pending
Recommendations Based on this consultation, accurately document the further recommendations from the C-MAT team which may include for example:
l Further tests- -Micro (blood cultures, swabs, fluids, tissue, stool, sputum, urine, serology, CSF, other) -Lab WCC ,CRP, Lactate, U/E, LFTs, antibiotic drug levels, Other) -New / Further Imaging ( Echo, CT, MRI, Bone Scan, Other )
l Antimicrobial therapy -Recommendations on antimicrobial therapy, choice of agent(s), dose optimisation, proposed length of treatment.
42Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016
Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
Appendix 10: Antimicrobial Dose Adjustment in Patients with Renal impairment
microbial Dose Adjustment in Pa ents with Renal impairment
***SEE NOTES ON OPPOSITE PAGE***
microbials where no dose adjustment is necessary (in adults)
Amphotericin iv (liposomal)15,17,20,21 Chloramphenicol iv17 Fusidic acid po/iv15,17
Anidulafungin iv15,17,20,21 Clindamycin iv15,17,20,21 Metronidazole po/iv15,17,21
Caspofungin iv15,17,20,21 Doxycycline po15,17,20,21
xone iv17,20,21 **Trimethoprim may cause hyperkalaemia in pa ents with renal impairment
microbial Mild Renal Impairment (GFR 20-50mls/min)
Moderate Renal Impairment (GFR 10-20mls/min)
Severe Renal Impairment (GFR <10mls/min)
Aciclovir iv
GFR 25-50mls/min 5-10mg/kg q12h17,21
GFR 10-25 mls/min 5-10mg/kg q24h17,21
2.5-5mg/kg q24h17,21
Amoxicillin
Dose as in normal renal fun on17
Dose as in normal renal fun on17
250mg-1g q8h (max 6g in 24h in endocard 17
Benzylpenicillin
Dose as in normal renal fun on17
600 mg – 2.4 g q6h depending on severity of infec on17
600 mg – 2.4 g q6h depending on severity of infec on17
Cefuroxime iv
Dose as in normal renal function
750mg-1.5g q12h17 750mg-1.5g q 24h17
Ciprofloxacin
Dose as in normal renal fun on17
10-30ml/min 50-100% of normal dose
50% of normal dose (100% dose may be given for short periods under exc onal circumstances)17
Clarithromycin
GFR 30-50mL/min Dose as in normal renal fun on17
GFR 10-30mL/min Oral: 250-500mg q12h IV: 250-500mg q12h17
Oral: 250-500mg q12h IV: 250-500mg q12h17
Co-amoxiclav
GFR 30-50mL/min Dose as in normal renal fun on17
GFR 10-30ml/min IV: 1.2g q12h Oral: Dose as in normal renal fun on17
IV:1.2g stat followed by 600mg q8h or 1.2g q12h Oral: Dose as in normal renal fun on17
Flucloxacillin
Dose as in normal renal fun on17
Dose as in normal renal fun on17
Dose as in normal renal fun on up to a total daily dose of 4g17
Fluconazole Reduce dose by 50%15 Levofloxacin
In l dose 250-500mg
In l dose 250-500mg then 125mg q12-24h17
In l dose 250-500mg then 125mg 12-48 hourly.
Meropenem 500mg-2g q12h17,21
500mg-1g q12h or 500mg q8h17,21
500mg-1g q24h17,21
Nitrofurantoin Contraindicated17 Contraindicated17 Contraindicated Piperacillin/ Tazobactam (TAZOCIN®)
Dose as in normal renal fun on17,21
4.5g q12h,
4.5g q12h
Teicpolanin
Give normal loading dose, then 200-400mg q48-72h17
Trimethoprim** Dose as in normal renal fun on17
GFR <15 give 50-100% of dose.17 GFR <15 give 50-100% of dose.17
17
50-100% of normal dose
then 125-250mg 12-24 hourly
50-100% of normal dose
GFR (mL/min): 40-60Dose as in normal renal function, then reduce dose after 4th day to200mg daily or 400mg every 48H
GFR (mL/min): <40Dose as in normal renal function, then reduce dose after 4th day to30% of the dose daily or 400mg every 72H
This table is for guideline purposes only and correct at time of publication (July 2016)Consult most up-to-date SPC / renal drug database before prescribing.
(26-50ml/min) (10-25ml/min)or 1gTDS
43
Antimicrobial Dose Adjustment in Patients with Renal impairment
This table includes many of the antimicrobials recommended within these guidelines but is not exhaustive. Vancomycin, Gentamicin & Amikacin, please see relevant algorithms. For advice on an antimicrobial not listed, please contact pharmacy.
The majority of the published information available on dosing recommendations in renal impairment is based on the traditional Cockcroft and Gault estimation of creatinine clearance (CrCl). 2. Estimated Glomerular Filration Rate (eGFR) provided by the Modification of Diet in Renal Disease trial (MDRD) is now routinely used as a guide to renal impairment and is reported by biochemistry . eGFR is an estimate of GFR only. Creatinine must be stable (eGFR may be unreliable in acutely ill patients). eGFR is not valid in pregnancy, children or at extremes of body type (high or low BMI). Multiply eGFR by 1.21 for Black race. For advice on antimicrobial prescribing in patients on renal replacement therapy or peritoneal dialysis and
transplant patients please contact pharmacy or dialysis unit/consultant nephrologist.
For usual dose consult current BNF/SPC
FORMULA FOR RENAL FUNCTION CALCULATION CrCl = ( 140 – age) x weight (kg) x K Serum Cr(micromoles/L)
● K = 1.23 for males and 1.04 for females ● Weight = actual weight (use ODW* if obese SEE BOX with Formulae for weight calculations) ● If patient is anuric or intermittent dialysis, treat as CrCl < 10ml/min
FORMULAE FOR WEIGHT CALCULATIONS
FORMULAE FOR WEIGHT CALCULATIONS
● If actual weight > Ideal Body Weight (IBW) Dose is based on IBW
● If actual weight is < IBW use actual body weight
IBW (kg) = R+ (2.3kg X every inch over 5ft) R=50 for males and 45.5 for females
Obese patients (weight >120% IBW) use Obese Dosing Weight (ODW)ODW *(kg) = IBW+0.4 (Actual weight-IBW)
BMI = weight (kg)/height (m)2 see page 44
1 foot = 30.5cm 1 inch = 2.54cm
Antimicrobial Dose Adjustment in Patients with Renal impairment
This table includes many of the antimicrobials recommended within these guidelines but is not exhaustive. Vancomycin, Gentamicin & Amikacin, please see relevant algorithms. For advice on an antimicrobial not listed, please contact pharmacy.
The majority of the published information available on dosing recommendations in renal impairment is based on the traditional Cockcroft and Gault estimation of creatinine clearance (CrCl). 2. Estimated Glomerular Filration Rate (eGFR) provided by the Modification of Diet in Renal Disease trial (MDRD) is now routinely used as a guide to renal impairment and is reported by biochemistry . eGFR is an estimate of GFR only. Creatinine must be stable (eGFR may be unreliable in acutely ill patients). eGFR is not valid in pregnancy, children or at extremes of body type (high or low BMI). Multiply eGFR by 1.21 for Black race. For advice on antimicrobial prescribing in patients on renal replacement therapy or peritoneal dialysis and
transplant patients please contact pharmacy or dialysis unit/consultant nephrologist.
For usual dose consult current BNF/SPC
FORMULA FOR RENAL FUNCTION CALCULATION CrCl = ( 140 – age) x weight (kg) x K Serum Cr(micromoles/L)
● K = 1.23 for males and 1.04 for females ● Weight = actual weight (use ODW* if obese SEE BOX with Formulae for weight calculations) ● If patient is anuric or intermittent dialysis, treat as CrCl < 10ml/min
FORMULAE FOR WEIGHT CALCULATIONS
FORMULAE FOR WEIGHT CALCULATIONS
● If actual weight > Ideal Body Weight (IBW) Dose is based on IBW
● If actual weight is < IBW use actual body weight
IBW (kg) = R+ (2.3kg X every inch over 5ft) R=50 for males and 45.5 for females
Obese patients (weight >120% IBW) use Obese Dosing Weight (ODW)ODW *(kg) = IBW+0.4 (Actual weight-IBW)
BMI = weight (kg)/height (m)2 see page 44
1 foot = 30.5cm 1 inch = 2.54cm
Appendix 11: Formulae For Weight Calculation
15,21
microbial Dose Adjustment in Pa ents with Renal impairment
***SEE NOTES ON OPPOSITE PAGE***
microbials where no dose adjustment is necessary (in adults)
Amphotericin iv (liposomal)15,17,20,21 Chloramphenicol iv17 Fusidic acid po/iv15,17
Anidulafungin iv15,17,20,21 Clindamycin iv15,17,20,21 Metronidazole po/iv15,17,21
Caspofungin iv15,17,20,21 Doxycycline po15,17,20,21
xone iv17,20,21 **Trimethoprim may cause hyperkalaemia in pa ents with renal impairment
microbial Mild Renal Impairment (GFR 20-50mls/min)
Moderate Renal Impairment (GFR 10-20mls/min)
Severe Renal Impairment (GFR <10mls/min)
Aciclovir iv
GFR 25-50mls/min 5-10mg/kg q12h17,21
GFR 10-25 mls/min 5-10mg/kg q24h17,21
2.5-5mg/kg q24h17,21
Amoxicillin
Dose as in normal renal fun on17
Dose as in normal renal fun on17
250mg-1g q8h (max 6g in 24h in endocard 17
Benzylpenicillin
Dose as in normal renal fun on17
600 mg – 2.4 g q6h depending on severity of infec on17
600 mg – 2.4 g q6h depending on severity of infec on17
Cefuroxime iv
Dose as in normal renal function
750mg-1.5g q12h17 750mg-1.5g q 24h17
Ciprofloxacin
Dose as in normal renal fun on17
10-30ml/min 50-100% of normal dose
50% of normal dose (100% dose may be given for short periods under exc onal circumstances)17
Clarithromycin
GFR 30-50mL/min Dose as in normal renal fun on17
GFR 10-30mL/min Oral: 250-500mg q12h IV: 250-500mg q12h17
Oral: 250-500mg q12h IV: 250-500mg q12h17
Co-amoxiclav
GFR 30-50mL/min Dose as in normal renal fun on17
GFR 10-30ml/min IV: 1.2g q12h Oral: Dose as in normal renal fun on17
IV:1.2g stat followed by 600mg q8h or 1.2g q12h Oral: Dose as in normal renal fun on17
Flucloxacillin
Dose as in normal renal fun on17
Dose as in normal renal fun on17
Dose as in normal renal fun on up to a total daily dose of 4g17
Fluconazole Reduce dose by 50%15 Levofloxacin
In l dose 250-500mg
In l dose 250-500mg then 125mg q12-24h17
In l dose 250-500mg then 125mg 12-48 hourly.
Meropenem 500mg-2g q12h17,21
500mg-1g q12h or 500mg q8h17,21
500mg-1g q24h17,21
Nitrofurantoin Contraindicated17 Contraindicated17 Contraindicated Piperacillin/ Tazobactam (TAZOCIN®)
Dose as in normal renal fun on17,21
4.5g q12h,
4.5g q12h
Teicpolanin
Give normal loading dose, then 200-400mg q48-72h17
Trimethoprim** Dose as in normal renal fun on17
GFR <15 give 50-100% of dose.17 GFR <15 give 50-100% of dose.17
17
50-100% of normal dose
then 125-250mg 12-24 hourly
50-100% of normal dose
GFR (mL/min): 40-60Dose as in normal renal function, then reduce dose after 4th day to200mg daily or 400mg every 48H
GFR (mL/min): <40Dose as in normal renal function, then reduce dose after 4th day to30% of the dose daily or 400mg every 72H
44
Appendix 11
45Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016
Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
Appendix 12: Other guideline documents to consult in association with these guidelines.
1. Guidelines for Restricted and Reserve Antimicrobials
2. Guidelines for Surgical Prophylaxis
3. South East Regional Orthopaedic Service antibiotic prophylaxis guidelines for open fractures
4. Local/National guidelines for treatment of diabetic foot infections including diabetic foot osteomyelitis
5. Post Splenectomy guidelines in adults
Individuals with an absent or dysfunctional spleen are at increased risk of severe infection, particularly with invasive pneumococcal disease. Patients must be informed of the risk, educated on how to recognise symptoms of infection and advised to seek urgent medical attention if unwell.
All patients should receive pneumococcal, Haemophilus influenzae type b and meningococcal vaccination. Vaccines should ideally be administered 2 weeks before splenectomy. If this is not possible they should be given 2 weeks after splenectomy.
All patients should receive antibiotic prophylaxis for at least 1 to 2 years. High risk patients should be offered life long antibiotic prophylaxis. Non high risk patients may choose to continue or discontinue antibiotic prophylaxis after the initial 1 to 2 year period based on a discussion of the risks and benefits of prophylaxis.
Please refer to relevant section in guideline document: Guidelines for surgical prophylaxis for full details of vaccination schedule, risk stratification of patients and antibiotic prophylaxis.
6. BNF and SPCs (Summary of Product Characteristics) and renal drug database for guidance on dosing, renal and hepatic impairment, adverse drug reactions and interactions.
Note: These guidelines are for adults only. For paediatric antimicrobial guidelines refer to local/ national paediatric guidelines.
Appendix 13: Penicillin Allergy
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
* It is important to document exactly what symptoms occurred before deciding if a patient is truly penicillin allergic. Check with Patient / Relatives / GP / Community Pharmacist to clarify the nature of allergic reaction.
• ManypatientsaremisdiagnosedasbeingPenicillinallergic• Anincorrectdiagnosisofpenicillinallergyleadstounnecessaryavoidanceofthisrelativelynon-toxicclassofdrugs,
exposes the patient to potentially more toxic drugs, increases health care costs and contributes to the development of antibiotic resistance.
• Patientsareoftenlabelledashavingahypersensitivityreactionwheninfactapatientmaybeexperiencingasideeffect of penicillin, such as gastrointestinal upset (e.g. nausea, diarrhoea) or headache.
• Otherconcomitantmedicinescanalsoberesponsiblefortriggeringahypersensitivityreaction.Therefore,itisimportant to consider the timeframe over which the hypersensivity reaction has developed relative to the initiation of different medications.
* Patients who have previously presented with a less severe penicillin allergy (e.g. rash) may be prescribed cephalosporins/carbapenems if the benefits outweigh the risks of cross reactivity. The potential for an allergic reaction should be monitored and resuscitation equipment available if required.
* Patients who are documented as having experienced a severe reaction (anaphylaxis) from a penicillin should not be prescribed cephalosporins, carbapenems and other betalactam containing antibiotics where acceptable alternatives available. A risk-benefit assessment may be needed in certain circumstances. Discuss individual case with senior clinician and clinical microbiology team if needed.
CONTRA-INDICATED*
CAUTION*
AmoxicillinAugmentin* (co-amoxiclav)Benzathine penicillinFlucloxacillinHeliClear*Penicillin C (benzylpenicillin)Penicillin V (phenoxymethyl)Piperacillin
Procaine penicillinTazocin* (piperacillin plus tazobactam)Timentin* (ticarcillin plus clavulanic acid)
CefalexinCefiximeCefotaximeCefazolinCeftazidimeCeftriaxone
CefuroximeImipenem plus cilastatinMeropenemAztreonam
In all patients with Penicllin allergy
May be safe to use in patients with non-type 1 penicillin hypersensitivity (NOT IgE
mediated reaction/anaphylaxis).
Common antimicrobials listed - List not exhaustive
Common antimicrobials listed - List not exhaustive
46
47Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016
Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
Contact Numbers
Microbiology Department UHW:
University Hospital Waterford switch 051-848000
Microbiology SpRs Ext. 8053
Dr. M. Hickey Ext.
Dr. M. Doyle Ext. 2621/2097
Dr. B. Carey Ext.
Dr. C. Fielding Ext.
Pharmacy Departments:
UHW Antimicrobial Pharmacist Ext. 2530/2453
WGH Antimicrobial Pharmacist Ext. 3261
SLKK/Kilcreene Antimicrobial Pharmacist Ext. 5372/5328
STGH Antimicrobial Pharmacist Ext. 7119
48
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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.
11. Royal College of Obstretricians Green top guideline no 64A Bacterial Sepsis in Pregnancy. 12. HSE Adult Patient Observation Chart. 13. Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland Update of 2008
Guidance HPSC 201314 Sepsis Management. National Clinical Guideline No.6. National Clinical Effectiveness Committee, Nov.
201415 BNF 59 March – September 201516 Gilbert N, Chambers F, Eliopoulos G et al Sanford Guide to Antimicrobial Therapy 2014 44th Edition17 Ashley C, Dunleavy A. 2014. The renal drug database. Available at www.renaldrugdatabase.com18 Amikacin Product SPC accessed online 29th May 2015 on www.medicines.ie19 Ali MZ & Goetz MB: A meta analysis of the relative efficacy and toxicity of single daily dosing versus
multiple daily dosing of aminoglycosides. Clin Infect Dis 1997; 24;20 UpToDate, www.uptodate.com21 Summary of Product Characteristics (SPC) www.medicine.ie22 Guidelines for the Prevention and Control of Multi-drug resistant organisms (MDRO) excluding MRSA
in the healthcare setting. Published on behalf of the Royal College of Physicians clinical advisory group on Healthcare Associated infections in association with HSE Quality and Patient Safety
23 Guidelines for Emergency Management of Injuries. 2012. www.emitoolkit.ie
49Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals July 2016
Index no ASG 001 Date of Approval July 2016, Revision Date July 2017, Revision no 10
Guidelines for the empiric use of antimicrobials in adults2016 - 2017