your hospitals, your health, our priority STANDARD OPERATING PROCEDURE: ANTIBIOTICS FOR SURGICAL PATIENTS SOP NO: TW SOP 3 VERSION NO: 9

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1 STANDARD OPERATING PROCEDURE: ANTIBIOTICS FOR SURGICAL PATIENTS SOP NO: TW SOP 3 VERSION NO: 9 APPROVING COMMITTEE: DATE THIS VERSION APPROVED: RATIFYING COMMITTEE: DATE THIS VERSION RATIFIED: AUTHOR(S) DIVISION/DIRECTORATE TRUST WIDE SOP (YES/NO) LINKS TO OTHER POLICIES, SOP S, STRATEGIES ETC: MEDICINES MANAGEMENT STRATEGY BOARD MAY 2013 PARC (Policy Approval and Ratification Committee) July 2013 CONSULTANT MICROBIOLOGIST MEDICINE YES TW Antimicrobial Prescribing Policy TW10/136 (SOP2) Antibiotic Prophylaxis: Guidance for Splenectomy, Meningitis and Endocarditis TW10/136 (SOP 1) Trust Antibiotic Treatment TW10/042 (SOP 13) Clostridium difficile Infection (CDI) Treatment Date(s) previous version(s) approved (if known): Version: DATE OF NEXT REVIEW: July 2016 Date: March 1999 November 2002 May 2005 September 2007 June 2009 May 2010 August 2010 June 2011 Manager Responsible for Review: your hospitals, your health, our priority Consultant Microbiologist

2 AT ALL TIMES, STAFF MUST TREAT EVERY INDIVIDUAL WITH RESPECT AND UPHOLD THEIR RIGHT TO PRIVACY AND DIGNITY Contents Page No. 1 Surgical Prophylaxis 2 2 Non-surgical Prophylaxis 6 3 Empirical Antibiotic Treatment Guidelines 7 4 Human Rights Act 16 5 Accessibility Statement 16 6 Monitoring & Review 16 7 Equality Impact Assessment 16 Appendices App 1 References 17 App 2 Antibiotic Monitoring (Gentamicin Levels) 18 1

3 1. SURGICAL ANTIBIOTIC PROPHYLAXIS Infection of the incised skin or soft tissue is a common but potentially avoidable complication of any surgical procedure. Some bacterial contamination of a surgical site is inevitable, usually form the patient s own bacterial flora and occasionally from the environment. 1.1 The goals of prophylactic administration of antibiotics to surgical patients are to: Reduce the incidence of surgical site infection Use antibiotics in a manner that is supported by evidence of effectiveness Minimise the effect of antibiotics on the patient s normal bacterial flora Minimise adverse effects and costs. Studies have shown that giving additional antibiotic prophylaxis after wound closure does not reduce infection rates further and can result in harm, predisposing patients to infection with Clostridium difficile, a cause of antibiotic-associated diarrhoea. 1.2 General Principles of Administration of Prophylactic Antibiotics The antibiotics selected for prophylaxis must possess good activity against organisms most likely to contaminate the operative site Prophylactic antibiotics should be administered intravenously. High antibiotic levels, at the site of incision, for the duration of operation are essential for effective prophylaxis Prophylaxis should be given preoperatively, towards the end of induction of anaesthesia, ensuring that surgery starts within 30 minutes of this time whenever possible Single dose of prophylactic antibiotic(s) is generally recommended An additional intra-operative dose is recommended if there is major blood loss (>1500ml) after fluid replacement Patients with a history of anaphylaxis or urticaria or rash occurring immediately after penicillin therapy should NOT receive prophylaxis with a β-lactam antibiotic (i.e. penicillin s, co-amoxiclav, cephalosporins, piperacillin/tazobactam or imipenem) Antibiotic prophylaxis should be recorded on the anaesthetic chart so that it is immediately clear whether a patient has received the correct prophylaxis both for clinical management and audit. The recommendations contained in this policy are based on local information about the epidemiology of drug-resistant bacteria and apply to average size adult patients with normal liver and renal function. 2

4 1.3 Surgical Prophylaxis SURGERY REGIMEN OF CHOICE ALTERNATIVE REGIMEN (ALLERGIC PATIENTS) HEAD AND NECK Procedures with incision through the oral or pharyngeal mucosa Cefuroxime IV 1.5g plus Gentamicin IV 1.5mg/kg plus clindamycin IV 600mg x 1 THORAX Breast cancer surgery Breast reshaping procedures Breast surgery with implant Cardiac pacemaker insertion Flucloxacillin IV 1-2g x 1 UPPER GASTROINTESTINAL Oesophageal surgery. Cefuroxime IV 1.5g plus Teicoplanin IV 400mg x 1 Gentamicin IV 1.5mg/kg plus Gastroduodenal surgery. Gastric resection. Gastroplasty. Cefuroxime IV 1.5g x 1 HEPATO BILIARY Bile duct surgery. Pancreatic surgery. Liver surgery. Gall bladder surgery (open). Laparoscopic gall bladder surgery in high-risk patients only: intro-operative cholangiogram, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy, immunosuppression, insertion of prosthetic devices. THERAPEUTIC ENDOSCOPIC PROCEDURES Percutaneous Endoscopic Gastrostomy. Endoscopic retrograde cholangio-pancreatography (ERCP) in high-risk patients: pancreatic pseudocyst, incomplete biliary drainage (eg. cholangiocarcinoma) immunosuppression. Gentamicin IV 1.5mg/kg. Cefuroxime IV 1.5g x 1 Gentamicin IV 1.5mg/kg x 1 Co-amoxiclav IV 1.2g x 1 Teicoplanin IV 400mg x 1 Ceftazidime IV 2g x 1 Ciprofloxacin IV 400mg x 1 dose or 750mg PO 1 hour before procedure. 3

5 SURGERY REGIMEN OF CHOICE ALTERNATIVE REGIMEN (ALLERGIC PATIENTS) LOWER GASTROINTESTINAL Appendectomy. Colorectal surgery. Perforated abdominal viscus. See also treatment recommendations on page 9. VASCULAR Abdominal and lower limb arterial reconstruction Lower limb amputation. UROGENITAL Transrectal prostate biopsy TURP TURBT Ureteroscopy. Retrograde examination. Optical urethrotomy. Stone surgery. Ileal conduit. Cefuroxime IV 1.5g plus Cefuroxime IV 1.5g plus Pre-op: Co-amoxiclav IV 1.2g x 1 Post-op: Co-amoxiclav IV 1.2g every 8 hours x 5 days. Pre-op: Co-amoxiclav IV 1.2g Post-op: Co-amoxiclav IV 1.2g every 8 hours for maximum of 48 hours (6 doses). Pre-op: Cefuroxime IV 1.5g plus metronidazole IV 500mg. Post-op: Cefuroxime IV 750mg plus metronidazole IV 500mg every 8 hours for 5 days. Pre-op Ciprofloxacin PO 500mg x 1 dose 1 hour before procedure. Post-op Ciprofloxacin PO 500mg every 12 hours x 3 days. Pre-op: Gentamicin IV up to 5mg/kg x 1 dose (Consultant Urologist to determine dose). Post-op (only for patients with preop urinary catheter): Ciprofloxacin PO 500mg every 12 hours x 3 days. Cefuroxime IV 1.5g plus Gentamicin IV 1.5mg/kg plus Gentamicin IV 1.5mg/kg plus Pre-op: Tigecycline IV 100mg x 1 Post-op: Tigecycline IV 50mg every 12 hours x 5 days. Pre-op: Teicoplanin IV 400mg plus gentamicin IV 1.5mg/kg. Post-op: Teicoplanin IV 400mg plus gentamicin IV 1.5mg/kg every 12 hours (2 doses). Pre-op: Metronidazole IV 500mg. Post-op: Metronidazole IV 500mg every 8 hours for 5 days. Ciprofloxacin IV 400mg plus Colposuspension Co-amoxiclav IV 1.2g x 1 Ciprofloxacin IV 400mg plus 4

6 SURGERY REGIMEN OF CHOICE ALTERNATIVE REGIMEN (ALLERGIC PATIENTS) OBSTETRICS AND GYNAECOLOGY Hysterectomy (abdominal or vaginal). TVT or TVT-O or TOT (tension free vaginal tapes) Co-amoxiclav IV 1.2g x 1 Gentamicin IV 1.5mg/kg plus Co-amoxiclav IV 1.2g x 1 Ciprofloxacin IV 400mg x 1 dose plus metronidazole IV 500 mg or metronidazole 1g rectally x 1 Induced abortion. Metronidazole 1g rectally x 1 Post abortion: Doxycycline PO 100mg every 12 hours x 7 days. Tubal surgery. Post-op: Doxycycline PO 100mg every 12 hours x 7 days. Caesarean section. Cefuroxime IV 1.5g x 1 dose plus dose before skin incision. Repair of third or fourth degree tear. Retained placenta OTHER SURGERY Hernia repair with or without mesh. Cefuroxime IV 1.5g x 1 dose plus Cefuroxime IV 1.5g x 1 dose plus Antibiotic prophylaxis not recommended. IV Gentamicin 1.5mg/kg plus dose before skin incision. IV Gentamicin 1.5mg/kg plus Gentamicin IV 1.5mg/kg plus metronidazole IV 500mg x 1dose. Immunocompromise or taking immunosuppressant drugs incl. systemic corticosteroids. Traumatic wounds Bite wounds Surgery on MRSA patient Co-amoxiclav IV 1.2g x 1 Pre-op: Co-amoxiclav IV 1.2g x 1 Post-op: Co-amoxiclav IV 1.2g every 8 hours x 5 days. Teicoplanin IV 400mg instead of first choice or add teicoplanin to the first choice depending on the clinical situation. Consult Microbiologist if required. Pre-op: Ciprofloxacin IV 400mg plus clindamycin IV 600mg x 1 Post-op: Ciprofloxacin IV 400mg (PO 750mg) every 12 hours plus clindamycin IV 600mg (PO 450mg) every 6 hours x 5 days. 5

7 2. NON SURGICAL ANTIBIOTIC PROPHYLAXIS 2.1 Splenectomy See Trust Guidelines on Management of Asplenic/Hyposplenic Patients. 2.2 Antibiotic Prophylaxis for Endocarditis See Antibiotic Prophylaxis Guidance for Splenectomy, Meningitis and Endocarditis. 6

8 3 EMPIRICAL ANTIBIOTIC TREATMENT POLICY 3.1 Introduction This policy document is intended to be used by the Medical Staff in the Surgical Directorate to allow early institution of antibiotic therapy pending the results of cultures and clinical response. For further advice contact Consultant Microbiologists: Dr C Faris ext or Dr R Nelson ext Subsequent treatment should be reviewed regularly to take into account microbiology results as they become available. The regimes suggested are based on the knowledge of local prevalence of organisms and their antibiotic sensitivity patterns and represent a basis for evidence-based strategies. Cefuroxime, ceftriaxone, clindamycin and ciprofloxacin should be avoided except in the circumstances indicated by this policy. The second choice regime is intended to give an option in the event of severe penicillin allergy being present which would prevent the use of any eta-lactam antibiotic. Treatment of most infections should not exceed seven days. Intravenous antibacterial therapy should be reviewed after 48 hours. Depending on the clinical diagnosis antibiotics may no longer be indicated or an oral agent could be administered. All antimicrobials should be reviewed after 5 days and rewritten if necessary. Dosage recommendations apply to adult patients of average size with normal renal function. IV to Oral Switch Choice of Oral Agents IV Agent Oral Alternative Review antibiotic therapy after 48 hours. Stop if infection has been ruled out. In the absence of microbiology switch to oral antibiotic when signs of sepsis are resolving and the oral route is not compromised. Specific contraindications to oral switch o Meningitis o Endocarditis o Joint and bone infections Tazocin 4.5g TDS Ciprofloxacin 400mg BD Co-amoxiclav 1.2g TDS Clindamycin 900mg QDS Teicoplanin Flucloxacillin 1-2g QDS Benzylpenicillin 1.2g QDS Ceftriaxone 2g BD (meningitis) Ceftriaxone 1-2g OD Gentamicin Tigecycline (intra-abdominal infection) Meropenem 1g TDS Co-amoxiclav 625mg TDS Ciprofloxacin 750mg BD Co-amoxiclav 625mg TDS Clindamycin 450mg QDS Consult Microbiologist. Flucloxacillin 500mg QDS Amoxicillin 500mg TDS No oral switch. Complete IV course. Consult Microbiologist. Consult Microbiologist. Ciprofloxacillin 500mg BD plus metronidazole 400mg TDS. Consult Microbiologist. 7

9 Antibiotic Guidelines for Surgical Patients Approved: PARC Next review date: Condition Regimen Penicillin allergy/ Alternative regimens ABDOMINAL SEPSIS Perforated abdominal viscus. Generalised peritonitis. Localised abdominal abscess. Co-amoxiclav IV 1.2g every 8 hours for 5 days. Tigecycline IV 100mg once then 50mg 12 hourly for 5 days. Oral switch: Ciprofloxacillin 500mg BD plus metronidazole 400mg TDS to complete course. Cholangitis. Cholecystitis. Tazocin IV 4.5g every 8 hours. Tigecycline IV 100mg once then 50mg 12 hourly. Oral switch: as above. Severely ill with prior laparotomy and antibiotic therapy. Severe Pancreatitis Prophylactic Regime SEPSIS Tazocin IV 4.5g every 8 hours + gentamicin IV 7mg/kg* as a single daily Tazocin IV 4.5g every 8 hours. Duration of prophylaxis: 7 days. Tigecycline IV 100mg once then 50mg 12 hourly + gentamicin IV 7mg/kg/day*. Oral switch: as above. Seek Microbiology advice for penicillin allergic patient. Non-immunocompromised, unclear focus of infection. Febrile neutropenic (refer to Trust Guidelines for Management of Adults with Neutropenia). Tazocin IV 4.5g every 8 hour + gentamicin IV 7mg/kg single daily dose*. Meropenem IV 1g every 8 hours + [teicoplanin IV 400mg every 12 hours x 3 doses, then 400mg once daily]. Indications for teicoplanin: severe mucositis h/o ciprofloxacin prophylaxis, IV catheter related sepsis, MRSA colonisation. Seek Microbiology advice if penicillin allergy suspected. Seek Microbiology advice if penicillin allergy suspected. * Consult Microbiologist and/or Antimicrobial Pharmacist for dosing advice for patients with renal failure. 8

10 Condition Regimen Penicillin allergy/ Alternative regimens CLOSTRIDIUM DIFFICILE INFECTION (CDI) Review concurrent antibiotic treatment, PPIs or laxatives and discontinue them where possible. Initial episode in patient age <75 years with NO severe co-morbidities Initial episode in patient age 75 years and/or with severe co-morbidities (immunocompromise, organ failure) Severe CDI Life threatening CDI (hypotension, partial or complete ileus or toxic megacolon or CT evidence of severe disease). For full details, please refer to Clostridium difficile infection: Treatment on Microbiology Intranet site. Metronidazole oral/ NG 400mg 8 hourly for days. Vancomycin oral/ NG 125mg 6 hourly for days. Vancomycin oral/ NG 125mg 6 hourly for days. If no clinical response, dose may be increased to a max 500mg 6 hourly. Vancomycin oral/ng 500mg 6 hourly for days plus metronidazole IV 500mg 8 hourly. If ileus is present, then add vancomycin as a retention enema (500mg in 100ml normal saline per rectum 6 12 hourly). If oral route is compromised: metronidazole IV 500mg 8 hourly for days. If oral route is compromised: Metronidazole IV 500mg 8 hourly for 10 to 14 days plus intracolonic vancomycin 500mg in 100ml of normal saline every 6 to 12 hours and/or vancomycin 500mg 6 hourly by nasogastric tube. Consult Microbiologist for advice on the treatment of relapses. 9

11 Condition Regimen Penicillin allergy/ Alternative regimens SKIN AND SUBCUTANEOUS TISSUE INFECTIONS Flucloxacillin oral 500mg 6 hourly. Clarithromycin oral 500mg 12 hourly. Mild to moderate cellulitis. For 7 days. For 7 days. Severe/spreading cellulitis with systemic symptoms. NB. Providing there is clinical improvement IVs should be continued until cellulitis subsides, then change to oral antibiotics for 5 further days. Flucloxacillin IV 1-2g 6 hourly plus benzylpenicillin IV 1.2g 4-6 hourly. Teicoplanin IV 400mg every 12 hours for 3 doses then 400mg once daily. Cellulitis in patients with a history of MRSA colonisation or risk factors such as several hospital admissions within 6 months or nursing home resident. Outpatient management of severe cellulitis (Refer to Accident and Emergency protocol). Necrotising infection/gangrene/fasciitis. N.B. Treatment is primarily surgical. Surgical wound infection. Do not treat if wound is only colonised (i.e. there is no concomitant cellulitis or purulent discharge). Wound infection following human/animal bites. N.B. Consider Antitetanus prophylaxis. Consider Hepatitis B prophylaxis if human bite sustained. Pressure sores Uncomplicated. Teicoplanin IV 400mg every 12 hours for 3 doses then 400mg once daily. Ceftriaxone IV 1-2g daily. Tazocin IV 4.5g every 8 hours plus clindamycin IV 900mg every 6 hours. Ciprofloxacin IV 400mg every 12 hours plus clindamycin IV 900mg every 6 hours. Co-amoxiclav IV 1.2g every 8 hours. Clindamycin IV 600mg every 6 hours + ciprofloxacin IV 200mg every 12 hours. Co-amoxiclav IV 1.2g every 8 hours. Pressure relief and wound toilet only. Ciprofloxacin IV 400mg every 12 hours and clindamycin IV 600mg every 6 hours. With progressing cellulitis: Flucloxacillin IV 1g (oral 500mg) 6 hourly ± metronidazole oral 400mg 8 hourly for 7 days. Ceftriaxone IV 1g once daily ± metronidazole oral 400mg 8 hourly for 7 days. With progressing cellulitis and systemic Tazocin IV 4.5g 8 hourly. (Add teicoplanin if at high risk of MRSA ) symptoms: (Add teicoplanin if at high risk of MRSA ). Previous MRSA, hospital admission within 6 months, nursing home resident. Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (e.g. anaphylaxis, angioedema, facial/throat swelling). 10

12 Condition Regimen Penicillin allergy/ Alternative regimens DIABETIC FOOT INFECTIONS Diabetic foot Mild infection Cellulitis/ erythema < 2cm AND infection limited to skin or superficial subcutaneous tissue AND NO PREVIOUS antibiotic treatment. Diabetic foot Moderate infection Cellulitis extending >2cm OR Lymphangitis OR Deep tissue abscess OR failure of previous antibiotic. Diabetic foot Severe infection with systemic symptoms (fever, WBC, CRP), necrosis or osteomyelitis. Flucloxacillin (oral or IV) 1g 6 hourly. For 1 2 weeks. Co-amoxiclav IV 1.2g (oral 625mg) 8 hourly. For 2-4 weeks. Tazocin IV 4.5g 8 hourly plus clindamycin IV 900mg 6 hourly. For 2-4 weeks. (Add teicoplanin if at high risk of MRSA ). Clindamycin oral 450mg 6 hourly. For 1-2 weeks. Ciprofloxacin oral 750mg (IV 400mg) 12 hourly plus clindamycin oral 450mg (IV 600mg) 6 hourly. Ciprofloxacin IV 400mg (oral 750mg) 12 hourly plus clindamycin IV 900mg (oral 450mg) 6 hourly. (Add teicoplanin if at high risk of MRSA ). Necrotising fasciitis Tazocin IV 4.5g 8 hourly plus clindamycin IV 900mg 6 hourly. Ciprofloxacin IV 400mg 12 hourly plus clindamycin IV 900mg 6 hourly. IV therapy until stable, then oral antibiotics for 2 to 4 weeks in the absence of osteomyelitis. Previous MRSA, hospital admission within 6 months, nursing home resident. 11

13 Condition Regimen Penicillin allergy/ Alternative regimens 3.7 URINARY TRACT Uncomplicated lower UTI Nitrofurantoin # oral 50mg 6 hourly for 3-7 daysŧ. Patient with egfr < 60mls/min, co-amoxiclav oral 375mg 8 hourly for 3-7 daysŧ. OR Cefalexin oral 500mg 12 hourly for 3-7 daysŧ. Complicated UTI/Pyelonephritis Factors suggesting a complicated UTI: Male patients, pregnant, diabetes mellitus, renal tract abnormalities, recent urinary surgery/instrumentation (excluding urinary tract catheterisation), indwelling urinary catheter, symptoms persisting for over 7 days, recent broad spectrum antibiotics. Empirical co-amoxiclav oral 625mg (or IV 1.2g) 8 hourly + IV gentamicin* 7mg/kg/day. Duration of treatment: 7-14 days. Gentamicin indicated if there are concerns of multi-drug resistant organisms. Known sensitivity trimethoprim oral 200mg 12 hourly. Duration of treatment: 10 days. Severe sepsis associated with UTI Tazocin IV 4.5g 8 hourly + IV gentamicin* 7mg/kg/day. Ceftriaxone IV 1-2g once daily + IV gentamicin* 7mg/kg/day. Catheter-associated UTI (CAUTI) All catheters become colonised by bacteria and growth of organisms from a CSU is NOT an indication for antibiotic treatment in the absence of clinical evidence of infection. Symptoms suggestive of CAUTI New loin or suprapubic tenderness Rigors New onset delirium Fever >38 o C or 1.5 o C above baseline on two occasions during 12 hours. Send urine for culture only if clinically indicated by above symptoms. Obtain sample from new catheter and await culture results if possible. CAUTI with systemic features of sepsis (Systemically unwell 2 or more of following: Temp>38 or <36, HR >90, RR>20, WBC >12 or <4). Co-amoxiclav PO 625mg 8 hourly + gentamicin* IV 7mg/kg/day (max 560mg). Duration of treatment: 7 days. Gentamicin indicated if there are concerns of multi-drug resistant organisms. IV tazocin 4.5g 8 hourly + IV gentamicin* 7mg/kg/day. # Nitrofurantoin - Contraindicated if egfr <60ml/min. Ŧ For uncomplicated cystitis in women without a catheter give 3 days course; for all other patients give 7 days. Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (e.g. anaphylaxis, angioedema, facial/throat swelling). * Consultant Microbiologist/Antimicrobial Pharmacist for dosing advice for patients with renal failure. 12

14 Condition Regimen Penicillin allergy/ Alternative regimens Epididymo-orchitis. Age <35 years [most probably due to gonococcal and/or chlamydia infection]. Ceftriaxone IM 250mg single dose plus doxycycline oral 100mg every 12 hours for 10 days. Age >35 years [most probably due to enteric organisms]. Acute prostatitis. Chronic bacterial prostatitis [treatment should be guided by antibiotic sensitivities]. Chronic abacterial prostatitis/chronic pain syndrome [unknown aetiology]. Ciprofloxacin oral 500mg every 12 hours for 10 days. Ciprofloxacin oral 500mg every 12 hours for 4 weeks. OR Ceftriaxone IV 2g once daily plus gentamicin IV* if severe. Ciprofloxacin oral 500mg every 12 hours for 4 weeks OR Doxycycline oral 100mg every 12 hours for 4 weeks. If a trial of antibiotic is considered, treat as for chronic bacterial prostatitis. * Consult Microbiologist and/or Antimicrobial Pharmacist for dosing advice for patients with renal failure. Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (e.g. anaphylaxis, angioedema, facial/throat swelling). 13

15 Condition Regimen Penicillin allergy/ Alternative regimens RESPIRATORY TRACT Community-acquired pneumonia Evidence of consolidation on CXR. Clinical findings & severity rating using CURB-65 score must be documented: C = Confusion (AMTS<8) 1 point. U = Urea >7 1 point. R = Respiratory Rate >30 1 point. B = SBP <90 or DBP <60 1 point. 65 = Age >65 1 point. Collect sputum and blood cultures if pyrexial. Legionella urine antigen and nose and throat swabs (VTM) for respiratory viruses. Mild (CURB-65: 0-1): Amoxicillin oral 500mg 8 hourly for 5 days. Moderate CAP (CURB-65: 2): Amoxicillin 500mg-1g (oral or IV) 8 hourly plus clarithromycin oral 500mg 12 hourly for 7 days. Severe CAP (CURB-65: 3): Co-amoxiclav IV 1.2g 8 hourly plus clarithromycin (IV or oral) 500mg 12 hourly. Review IV after 48 hours. Doxycycline oral 200mg day 1 then 100mg hourly for 6 days. OR clarithromycin oral 500mg 12 hourly for 5 days. Ceftriaxone IV 1g once daily plus clarithromycin oral 500mg 12 hourly for 7 days. Review IV after 48 hours. Ceftriaxone IV 1-2g once daily plus clarithromycin (IV or oral) 500mg 12 hourly. Review IV after 48 hours. Hospital-acquired pneumonia. Tazocin IV 4.5g 8 hourly 7 days. Ceftriaxone IV 1-2g once daily plus metronidazole IV 500mg 8 hourly ± gentamicin IV 7mg/kg/day*. Aspiration with evidence of pneumonia. Aspiration has occurred in the community. Benzylpenicillin IV 1.2g every 6 hours + metronidazole IV 500mg every 8 hours for 7 days. Ceftriaxone IV 1g once daily plus metronidazole IV 500mg every 8 hours. Aspiration has occurred on the ward (>48 hours from admission) EPIGLOTTITIS EYE INFECTIONS Conjunctivitis. Tazocin IV 4.5g every 8 hours for 7 days. Cefuroxime IV 1.5g every 8 hours Chloramphenicol 1% eye ointment every 6 hours for 5 days OR Gentamicin eye drops 0.3%. Ceftriaxone IV 1-2g once daily plus metronidazole IV 500mg every 8 hours + gentamicin IV 7mg/kg/day*. Seek Microbiology advice if penicillin allergy present. Keratitis/Orbital cellulitis seek Ophthalmology/Microbiology advice. Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (e.g. anaphylaxis, angioedema, facial/throat swelling). * Consult Microbiologist and/or Antimicrobial Pharmacist for dosing advice for patients with renal failure. 14

16 Condition Regimen Penicillin allergy/ Alternative regimens MRSA MRSA systemic or life-threatening infections. MRSA colonisation (nose, throat, intact skin). Refer also to Infection Control MRSA Guidelines for risk assessment and treatment of MRSA colonisation. MRSA-other infections. Teicoplanin IV 10-12mg/kg every 12 hours for first 3 doses then 10-12mg/kg once daily alone or in combination with rifampicin oral mg 12 hourly. Oral antibiotic step-down discuss with a Consultant Microbiologist. For 14 days. Bactroban Nasal three times daily for 5 days. Antiseptic skin cleanser (e.g. Octenisan or others) for daily bathing and shampooing for 5 days. Discuss with a Consultant Microbiologist, as these infections often require combination therapy. Consult Microbiologist for advice. Consult Infection Control for advice. 15

17 Antibiotic Guidelines for Surgical Patients Approved: PARC Next review date: 4. HUMAN RIGHTS ACT Implications of the Human Rights Act have been taken into account in the formulation of this policy and they have, where appropriate, been fully reflected in its wording. 5. ACCESSIBILITY STATEMENT This document can be made available in a range of alternative formats e.g. large print, Braille and audiocassette. Form more details please contact HR Department on (3766) or equalityanddiversity@wwl.nhs.uk 6. AUDIT MONITORING AND REVIEW: The processes contained within this SOP will be; audited, monitored and reviewed in line with the audit and monitoring template contained within Antimicrobial Prescribing Policy TW EQUALITY AND DIVERSITY ASSESSMENT: The completed assessment is contained within the associated Antimicrobial Prescribing Policy TW

18 REFERENCES: APPENDIX 1 Platell C and Hall JC. The prevention of wound infection in patients undergoing colorectal surgery. Journal of Hospital Infection 2001; 49: Song F and Glenny AM. Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomised controlled trials. British Journal of Surgery 1998; 85: Allison MRSA colonisation et al. Antibiotic prophylaxis in gastrointestinal endoscopy. Gut 2009;58: ( Prophylactic Therapy. In the Sandford Guide to Antimicrobial Therapy 13 th Edition, 2000, pg JE Conte jr. Antibiotic Prophylaxis. In Manual of Antibiotics and Infectious Diseases Treatment and Prevention 9 th Edition, 2002, pg British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia. Thorax 2001; 56 (Suppl 4): Working Party of Clinical Haematology Task Force. The prevention and treatment of infection in patients with absent or dysfunctional spleen (up-date). Accessed 6 November Sainio V et al. Early antibiotic treatment in acute necrotising pancreatitis. Lancet 1995; 346: ASHP. Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. American Journal of Health System Pharmacy (18): Revised Guidelines for the Control of Methicillin-resistant Staphylococcus aureus Infection in Hospitals. J Hosp Infection 1998; 39: Boyce JM. MRSA Patients: proven methods to treat colonisation and infection. J. Hosp. Infection 2001; 38 (Suppl. A): S9 14. Clinical Effectiveness Group (Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). National Guideline for the Management of Epididymo-orchitis, ( Accessed 15 th January Clinical Effectiveness Group (Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). National Guideline for the Management prostatis, ( Accessed 15 th January SIGN 104. Antibiotic Prophylaxis in Surgery, ( Accessed 5 May Penney GC. Prophylactic antibiotic therapy for abortion. The Prevention of Pelvic Infection (1996): RCOG, London In Templeton AA,ed. Antibacterial prophylaxis in surgery: Gastrointestinal and biliary surgery. Drugs and Therapeutics Bulletin 2003; 41 (11): Gemmell CG, Edwards DI, Fraise AP et al. Guidelines for the prophylaxis and treatment of MRSA infections in the UK. Journal of Antimicrobial Chemotherapy (2006) 57,

19 Antibiotic Monitoring (Gentamicin Levels) APPENDIX 2 Result Interpretation USE OF HARTFORD NOMOGRAM FOR HIGH-DOSE ONCE DAILY REGIMEN 1. Obtain a serum level after the first dose between 6-14 hours after the start of the infusion. It is very important that the exact time is documented. Plot the result on the nomogram. 2. If the level falls in the area designated Q24h, Q36h or Q48h, the dosing interval will be every 24, 36 or 48 hours respectively. If the point is on the line, choose the longer interval. 3. If the level is off the nomogram at the given time, stop the scheduled therapy and obtain serial levels until <2mg/litre, to determine the appropriate time of the next 4. Where appropriate, monitor blood level twice weekly. 5. Consult Microbiologist if in doubt. Exclusions to this protocol: Endocarditis, pregnancy, children, patients with ascites, major burns or cystic fibrosis, renal impairment. Hours between start of infusion and sample draw This nomogram was developed and validated by Dr David Nicolau et al, Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut, U.S.A. 18