References and supporting documents 5 Roles and responsibilities 5

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1 Antibiotic Therapy for Patients with Antibody Deficiency Guidelines for Classification: guidelines Lead Author: Dr Archana Herwadkar, Paul Chadwick Additional author(s): Dr Hana Alachkar Authors Division: Immunology, Renal and Tertiary medicine Unique ID: TWCIMM12(13) Issue number: 3 Expiry Date: September 2019 Contents Section Page Who should read this document 2 Key practice points 2 Background /scope/definitions 2 What s new in this version 2 Guideline 3-5 Standard 5 Explanation of terms/definitions 5 References and supporting documents 5 Roles and responsibilities 5 Appendix N/A Document control information (Published as separate document) Document Control 6 Policy Implementation Plan 7 Monitoring and Review 7 Endorsement 7 Equality analysis 8 Page 1 of 5

2 Who should read this document? Immunology specialist nurses and medical staff who are involved in the care and management of patients with antibody Other medical staff trust-wide managing the above patients GP Microbiologist Key Practice Points Recommendations of antibiotic use in patients with antibody Patient copy to empower GP copy to advise Background/ Scope/ Definitions. Patients with antibody are prone to recurrent bacterial infections and they often have chronic end organ damage by the time the diagnosis of antibody has been reached. Despite the fact that they are on antibody replacement therapy, they will continue to be at risk of bacterial infections and thus it is vitally important that bacterial infections are treated early with a full course of an appropriate dose of antibiotics. A failure to do so, particularly if the individual patient has multiple infections, may lead to progressive damage, i.e., bronchiectasis or perforated nasal septum/eardrum. These guidelines have been devised to assist with the optimum treatment for such patients with the most common infections that they are likely to encounter. We feel that is important that samples are sent to the microbiology department for culture and sensitivity for all immunodeficient patients, preferably before antibiotics are commenced. The antibiotics suggested below should be given until the culture result is available, at which time changes may need to be made depending on the antibiotic sensitivities of the organism isolated. If you have any concerns please do not hesitate to contact the department for further advice. What is new in this version? No changes to previous. Page 2 of 5

3 Guideline/ Protocol The antibiotics suggested below should be given until the culture result is available, at which time changes may need to be made depending on the antibiotic sensitivities of the organism isolated. If you have any concerns please do not hesitate to contact the department for further advice on /6. CHEST INFECTION Antibiotics are advised if the patient has symptoms suggestive of a bacterial chest infection in the form of two or more of the following: Pyrexia Deterioration of chest symptoms and signs Increased sputum volume Green sputum Amoxicillin 1 g tds days Second line therapy, or First line if Penicillin Allergic: Levofloxacin 500 mg daily days Alternative treatment for Haemophilus influenzae or other sensitive organisms: Doxycycline (200mg 1 st dose) then 100 mg daily days Repeated, sequential courses of the same antibiotic are unlikely to result in clinical improvement if the first course does not resolve the infection. Lower doses or shorter courses than suggested are likely to increase the chance of a persistent infection or of antibiotic resistance developing. If two courses of antibiotic therapy are insufficient to resolve the symptoms, a further sputum sample should be sent for microbiological examination and consideration should be given to performing a CXR, depending on the clinical findings. Whilst a result is awaited, Doxycycline would be suitable as a third line agent but you may wish to discuss the patient with a microbiologist. Page 3 of 5

4 BRONCHIECTASIS Patients with established bronchiectasis are prone to infection with Pseudomonas and if this infection is suspected it would be appropriate to commence the following as second line therapy. If the patient has had confirmed pseudomonal infection in the past then antibiotics choice should be discussed with the immunology consultant: Amoxicillin or levofloxacin as above Second Line therapy: Ciprofloxacin 750 mg bd 10 days SINUSITIS Many of our patients have recurrent sinusitis which may be isolated or may occur in addition to a chest infection. Amoxicillin 1 g tds days Second line therapy, or if allergic to Penicillin: Ciprofloxacin 750 mg bd 14 days GASTROINTESTINAL INFECTIONS Giardiasis is the most common gut infection and usually causes diarrhoea, loss of appetite and weight loss. It does not usually result in an acute gastroenteritis picture; this is usually due to organisms such as Salmonella and Campylobacter and can be rapidly progressive in immunodeficient patients. Again, samples for microbiology are very important in these patients. Treatment for Giardiasis: Metronidazole 400 mg tds 7 days Treatment for Bacterial Gastroenteritis: Ciprofloxacin 500 mg bd 5 days Page 4 of 5

5 For your convenience, a copy of this letter will also be given to your patient so that you can refer to it even if you do not have immediate access to their notes. If you have any further concerns or worries about your patient please contact the department to discuss it with one of the clinical members of staff Standards (section number should follow on from the preceding section) See supporting references. UKPIN Standards currently under review. Explanation of terms N/A References and Supporting Documents Chapel H, Prevot J, Gaspar HB, Español T, Bonilla FA, Solis L, Drabwell J and The Editorial Board for Working Party on Principles of Care at IPOPI (2014) Primary immune deficiencies principles of care. Front. Immunol. 5:627. doi: /fimmu Roles and responsibilities Immunology Team including: Consultant Immunologist, Specialist Registrar, and Immunology Specialist Nurses: To ensure that the patient is appropriately managed To ensure both patient and GP has a copy of these guidelines To provide the patient with ongoing support and information re management of infections and self care To review with cultures as appropriate To liaise with the GP/other consultants as appropriate To liaise with microbiologist as appropriate Page 5 of 5