Adult Empirical Antibiotic Pocketguide (Apr 2010)

Transcription

1 Adult Empirical Antibiotic Pocketguide (Apr 2010) Please refer to full guidance for details. All doses are for NON-PREGNANT ADULTS with NMAL renal and hepatic function. For advice on pregnant patients or patients with renal/hepatic impairment and for drug interactions: contact your ward pharmacist. Contacts: Dr Jorge Cepeda (Microbiologist) ext 3308 Dr Nicki Hutchinson (Microbiologist) ext 3310 Dr Fatima El-Bakri (Microbiologist) ext 3305 Antibiotic Pharmacist bleep 2435 Principles of Prudent Antimicrobial Prescribing Take specimens for culture before antibiotic is given, whenever Possible. Ensure there is a clinical justification to prescribe an antimicrobial agent. Document clearly the evidence of infection / diagnosis and antibiotic use including reviews in the patient s medical notes. Seek advice early from the Microbiologist for seriously ill or deteriorating patients and in the case of multiple allergies. Use oral route whenever possible. Ciprofloxacin, Clindamycin, Metronidazole, Sodium fusidate, Rifampicin & Fluconazole are all well absorbed from the gut and have excellent tissue and cell penetration. Unless the patient cannot absorb them from the gut there is NO advantage in using these drugs intravenously. Review all antimicrobial prescriptions on a daily basis in the light of the patient s clinical progress. o Check microbiology results for culture and sensitivities and de-escalate (move to a narrower spectrum antibiotic) as soon as the pathogen s sensitivity is known. o Stop any antibiotic started inappropriately or without sufficient evidence of infection. o Change from the IV route to the oral (PO) route as soon as is appropriate. As a general rule: prescribe IV antimicrobials for 2 days and oral agents for 7 days (or less) unless treating a serious or deep-seated infection. o Stop antimicrobial agents as soon as is clinically appropriate. Usually antibiotics can be stopped safely when the patient has fully recovered for 48 hours. Seek duty Microbiologist approval if you are going to send a clotted blood for antibiotic assay at weekends. Produced by Dr J Cepeda (Cons Microbiologist) & Taryn Keyser (Antibiotic Pharmacist) Ratified by Drugs and Therapeutics Committee Review Date Page 1 of 14

2 IV TO AL SWITCH PROTOCOL Is the patient receiving IV antibiotics and do ANY of the following apply? Oral route compromised Continuing Sepsis Special Indication (2 or more of the following - Vomiting - Temperature <36 o or >38 o C No appropriate oral - NBM - Heart Rate > 90 per minute agent available - Severe diarrhoea - Respiratory Rate > 20 per minute (See Table 2 below) - Unconscious - WCC < 4 or >12 - Swallowing disorder - Deteriorating clinical condition (And with no feeding tubes) YES Consider targeted therapy on the basis of clinical picture and/or Microbiology results* NO Switch to oral therapy after 24 hours of clinical stability (See Table 1) * Review need for IV therapy again after 24 hours (mark new review date on chart) NOTE: Some multi-drug resistant organisms need treatment with agents only available intravenously Infections that may require an initial two weeks of IV therapy - Liver abscess - Osteomyelitis, septic arthritis (N.B. high dose oral Clindamycin may be appropriate once patient is stable) - Empyema - Cavitating pneumonia High risk infections requiring prolonged IV therapy - Staphylococcus aureus bacteraemia - Severe necrotising soft tissue infections - Severe infections during chemotherapy related neutropenia - Infected implants/prosthesis - Meningitis/encephalitis - Intracranial abscesses - Mediastinitis - Endocarditis - Exacerbation of cystic fibrosis/bronchiectasis - Inadequately drained abscesses or empyema Amoxicillin 500mg- 1g TDS Clarithromycin 500mg BD Flucloxacillin 2g QDS Flucloxacillin 1-2g QDS + BenzylPenicillin 1.2g QDS IV BenzylPenicillin 1.2g -2.4g QDS Co-amoxiclav 1.2g TDS TABLE 1 Amoxicillin 500mg- 1g TDS Clarithromycin 500mg BD Flucloxacillin 1g QDS Oral Flucloxacillin 1g QDS + Amoxicillin 500 mg TDS Amoxicillin 500mg-1g TDS Co-amoxiclav 375mg tds + Amoxicillin 250mg TDS Metronidazole 500mg TDS Metronidazole 500mg TDS Clindamycin 900mg-1.2g QDS Clindamycin mg QDS (Up to 600mg QDS if severe infection) Ciprofloxacin 400mg BD Ciprofloxacin 500mg-750mg BD Piperacillin/Tazobactam, Meropenem,, Vancomycin, Gentamicin Seek advice from Microbiology OD = BD = twice daily TDS = 3 times daily QDS = 4 times daily Page 2 of 14

3 SEPTICAEMIA (Assumes non-pregnant, normal renal/hepatic function) Take two sets of blood cultures from different sites if possible before starting antibiotics (3 sets with suspected endocarditis) Community acquired (stable patient) Community acquired (unstable patient) & hospital acquired Neutropaenic patients CVC related blood stream infection Peripheral line Intra-abdominal infections: Perforated gut or biliary sepsis Septic shock or suspected Gramnegative bacteria MSSA septicaemia At least 14 days. Suspected MRSA septicaemia Amoxicillin 1g IV TDS + Metronidazole 500mg IV TDS Piperacillin/Tazobactam 4.5g TDS IV + Gentamicin** 5 mg/kg (max 500mg) IV Piperacillin/Tazobactam 4.5g TDS IV If no response at 48 hours or deterioration earlier: + 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 hours apart then OD 10mg/kg (max 800mg per dose) IV 12 hourly for 3 doses the OD Flucloxacillin 1-2g QDS IV If known MRSA carrier: 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 Amoxicillin 1g IV TDS + Metronidazole 500mg IV TDS If four quadrant peritonitis/patient unstable: Piperacillin/Tazobactam 4.5g TDS IV Piperacillin/Tazobactam 4.5g TDS IV If MRSA risk: ADD 10mg/kg IV to nearest 100mg (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours CONSIDER antifungal therapy if high risk of invasive fungal infection Flucloxacillin 2 g IV QDS 70kg: 600mg IV for 3 loading doses 12 doses 12 + Metronidazole 500mg TDS IV Meropenem 1-2g IV TDS 70kg: 600mg IV for 3 loading doses 12 doses 12 + Metronidazole 500mg TDS IV Meropenem 2g tds If no response at 48 hours/deterioration: + 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 hours apart then OD Contact consultant Microbiologist 10mg/kg (max 800mg per dose) IV 12 hourly for 3 doses the OD 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 hours apart then OD 70kg: 600mg IV for 3 loading doses 12 doses 12 + Metronidazole 500mg TDS IV Meropenem 1-2g IV TDS 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 hours apart then OD + Metronidazole 500mg TDS IV 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 hours apart then OD 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 hours apart then OD Page 3 of 14

4 Early Antibiotic Administration in Septic Shock Criteria for Severe Sepsis (see Box 1) Senior Dr Review Fluid unresponsive? (20ml/kg crystalloid or equivalent) Yes No Take blood cultures x 2 and Give IV Antibiotics immediately according to source following trust guidelines 1. SEPTIC SHOCK: Hypotensive despite fluid resuscitation with clinical evidence of infection Sing 2. High risk for requiring vasopressors le within 4 hours (if not responsive to treatment below) Take blood cultures x 2 and give IV antibiotics immediately (Document as per Box 3) It is the responsibility of the doctor evaluating the patient to administer the antibiotics within 1 hour. Mortality for Septic Shock increases dramatically every hour antibiotics are not given. Piperacillin / Tazobactam 4.5g QDS for 48 hrs + Gentamicin** 5mg/kg (Max 500mg) Non-severe Penicillin allergy: 1 st Line Antibiotic Therapy If MRSA risk ADD 10mg/kg IV to nearest 100mg (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours + Caspofungin IV if high risk of invasive fungal infection For Continued Antimicrobial Use Especially MEROPENEM Meropenem 1gm 8 hourly *Check Gent level at 18 hours Severe penicillin allergy (anaphylaxis or urticarial reaction on exposure to penicillins or cephalosporins) Gentamicin** 5mg/kg (Max 500mg) If known CrCl < 60 use 3mg/kg (max 240mg) + 10mg/kg to nearest 100mg (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours + Metronidazole 500mg iv tds Contact Medical Microbiologist (Ext 3312/3307) Monday to Friday or via switchboard OOH Box 1: To diagnose Severe Sepsis patients must reach all three of the following criteria. 1. Known infection or clinical evidence suggestive of infection 2. Meet 2 or more of SIRS criteria Tachycardia 90 RR> 20 or PaCO2 <4.3 WCC >12 or <4 Temp 36 or Evidence of end organ hypo-perfusion Systolic BP <90 or MAP <65 Bilirubin > 35 Acute confusion Cr >180 or U/O <0.5ml/kg for 2 hours Platelets < 100 SpO2 <90% Lactate >2 Box 3: When patient is given antibiotics for Septic Shock please clearly document: Source of sepsis (if known) Time of diagnosis of SIRS / Severe Sepsis criteria & non response to fluid Time cultures sent Time antibiotics given Time blood taken for gentamicin levels Date and time of discussion with microbiology Page 4 of 14

5 GENTAMICIN Single daily dosing with gentamicin is recommended in most patients requiring aminoglycoside therapy. Exclusions: Endocarditis, prophylaxis, pregnancy and post-partum, children, patients with ascites, major burns, cystic fibrosis, dialysis, acute renal failure - seek specialist advice. Administration and monitoring for toxicity Calculate dose at 5mg/kg (based on actual body weight [ABW] unless patient is obese i.e. 20% over ideal body weight [IBW]) with initial interval of 24 hours. The usual maximum daily dose is 500mg. If elderly or frail, contact Microbiology/Pharmacy for dosage advice. Obese Dosing Weight (ODW): ODW (kg) = IBW (ABW IBW) Males: IBW = 50kg + 1kg for every cm over 150cm height Females: IBW = 45kg + 1kg for every cm over 150cm height Administer as an IV infusion in 100ml sodium chloride 0.9% or dextrose 5% over minutes. Arrange for bloods to be taken 6 14 hours after dose this is the prescriber s responsibility. Take 5-10mls blood in a clotted tube (yellow top). Record the exact sampling time and date of blood sample on request form. Record exact time and date of last gentamicin dose administered on request form. Monitor serum gentamicin level 6-14 hours after first dose using the Urban & Craig nomogram (below). If gentamicin level is normal (appropriate for daily dosing) and renal function is stable, there is no need to recheck level unless gentamicin therapy continues beyond 5 days. Only give for >48 hrs under direction from Microbiology. If first level is missed and if renal function is normal, give 2 nd dose after 24 hours and monitor serum gentamicin level 6 14 hours after 2 nd dose. If in exceptional circumstances, no gentamicin levels have been done, calculate creatinine clearance (see additional notes on below for equation) and contact pharmacist for advice. Monitor serum creatinine three times a week or daily if renal function unstable. Urban & Craig nomogram for 5mg/kg gentamicin dosing Request the Cockcroft & Gault Creatinine Clearance from Biochemistry: sex, age and weight need to be stated on the form or calculate using: CrCl (ml/min) = A x (140 - age) x Wt (kg) Serum Creatinine (µmol/l) A = 1.23 for males and 1.03 for females Page 5 of 14

6 Indication Bone and Joint infections S. aureus sepsis (MRSA, MSSA) Severe sepsis/septic shock Intravenous drug abusers Burns Other infections TEICOPLANIN Dosage 10mg/kg to nearest 100mg (maximum 800mg per dose) for 3 loading doses 12 hours apart then every 24 hours 70kg: 600mg IV for 3 loading doses 12 doses 12 Expected therapeutic trough levels 20 to 40 mg/l Send trough level before 4 th dose: if sub-therapeutic discuss with Microbiologist. Most patients do not require further drug level monitoring unless prolonged antibiotic therapy is scheduled. No need to monitor levels routinely unless acute renal failure* aim for: 10 to 40 mg/l *Renal Failure dosage: In severe renal failure full loading dose is required, subsequent maintenance dose will vary according to CrCl and use of renal replacement therapy, liaise with Pharmacist and/or Microbiologist. BONE & JOINT INFECTIONS (Assumes non-pregnant, normal renal/hepatic function) Osteomyelitis Switch to oral antibiotics after 4 weeks with culture results for targeted therapy. Discitis/ Vertebral osteomyelitis/ +/- epidural abscess (MRI required) Duration: at least 6weeks of IV Open fractures/ Major trauma Septic arthritis Duration: Uncomplicated 2-3weeks Septic Bursitis Prosthetic Joint Infection Duration of IV treatment: 6 weeks <65 years old Co-amoxiclav 1.2g TDS IV >65 years old Benzylpenicillin 1.2 g IV QDS + Flucloxacillin 2g IV QDS Flucloxacillin 2g QDS IV + Benzylpenicillin 2.4g QDS IV + Gentamicin 5mg/kg** (max 500mg) IV Hospital acquired 10mg/kg (maximum 800mg daily) IV 12 hourly for 3doses then OD + Meropenem 1g IV TDS Co-amoxiclav 1.2 g IV at induction, followed by two doses 8hourly (total of 3 doses in 24 hours) If heavy contamination add in: Metronidazole 500mg IV 8 hourly (2 doses) + Gentamicin 1.5mg/kg IV stat bolus at induction Benzylpenicillin 1.2 g QDS IV + Flucloxacillin 2g QDS IV Flucloxacillin 2g IV QDS for 3 weeks Switch to oral Flucloxacillin after 1 week Antibiotics should NOT be given until samples have been taken Single dose 10mg/kg (max 800mg per dose) IV after sampling + Meropenem 500mg IV after sampling If sepsis syndrome followed by: 10mg/kg (max 800mg per dose) IV BD for 2 doses then OD + Meropenem 500mg IV TDS Non severe allergy & <65 years old: Ceftriaxone 2g IV OD Severe allergy or >65 years old: 10mg/kg (max 800mg per dose) IV 12 hourly for 3 doses then OD 10mg/kg (max 800mg per dose) IV 12 hourly for 3 doses then OD + Rifampicin mg PO BD Gram-negative infection suspected: Add in Gentamicin 5mg/kg** (max 500mg) IV 10mg/kg (max 800mg per dose) IV + Gentamicin 1.5mg/kg IV stat at induction + Metronidazole 500mg IV stat at induction Followed by: 10mg/kg (max 800mg per dose) 12 hours after first dose (two doses in total) + Metronidazole 500mg IV 8 hourly (three doses in total) 10mg/kg (max 800mg per dose) IV 12 hourly for 3 doses then OD + Rifampicin 300 mg PO/IV BD Treat for 3 weeks 10mg/kg (max 800mg per dose) IV 12 hourly for 3 doses then OD +/- Rifampicin 300 mg PO/IV BD Single dose 10mg/kg (max 800mg per dose) IV after sampling + Gentamicin 1.5mg/kg IV stat bolus at induction If sepsis syndrome followed by: 10mg/kg (max 800mg per dose) IV BD for 2 doses then OD + Gentamicin 5mg/kg** (max 500mg) IV min infusion OD from day 2 onwards. Page 6 of 14

7 CENTRAL NERVOUS SYSTEM (Assumes non-pregnant, normal renal/hepatic function) Suspected bacterial Meningitis Antibiotics should be given immediately after blood cultures in severely ill patients Duration: days and review Please send in all cases: Throat swab for meningococcal culture & EDTA sample (2.5-5ml) for meningococcal PCR Suspected Viral Meningitis Suspected Viral Encephalitis Treatment to eliminate pharyngeal carriage (index case) Prophylaxis meningococcal disease Prophylaxis haemophilus influenzae type-b Brain abscess Duration: Four weeks of IV antibiotics and review Ceftriaxone 2g IV BD Cefotaxime 2g IV 4-6 hourly If Listeria spp or if resistant S. pneumoniae suspected (e.g. recent travel abroad): See full guidance Give Dexamethasone IV 10mg 6hourly for 2-4 days ONLY if this can be started before/ within 6hours of first antibiotic dose if NOT contraindicated Meropenem 2g IV TDS +/- Vancomycin mg IV QDS Chloramphenicol 100mg/kg/day IV in 4 divided doses (contact Microbiology) NOTE: max dose 4-6g/day. If Listeria spp or if resistant S. pneumoniae suspected (e.g. recent travel abroad): See full guidance NO neurological deficit: Treatment with anti-virals is not recommended unless there is evidence of focal neurological deficit / encephalitis All patients should have empirical antibiotic and antiviral initially. Aciclovir 10mg/kg every 8 hours IV (based on IBW) Duration: 14-21days and review Ceftriaxone eliminates carriage of meningococcus Patients who have not received Ceftriaxone should receive: Ciprofloxacin 500mg oral stat Rifampicin 600mg BD for 2 days (if Ciprofloxacin intolerant). Non-pregnant close contacts should be given Ciprofloxacin prophylaxis ( 12years) Rifampicin <12 months: 5mg/kg BD for 2 days 1-12 years: 10mg/kg BD for 2 days (maximum 600 mg BD) >12 years/adult: 600mg BD for 2 days If an unvaccinated child (<4years) lives in the same household as the patient, Rifampicin prophylaxis should be given to the entire household for 4 days (including the patient) 1-3months: 10mg/kg OD 3months-12 years: 20mg/kg OD (max 600mg) >12years/adult: 600mg OD Cefotaxime 2g IV 4 hourly + Metronidazole 500 mg IV 8 hourly + Rifampicin 600 mg OD PO If S. aureus suspected: Add Vancomycin mg IV QDS until sensitivity known Not severe allergy: Meropenem 2g TDS (8hourly) + Rifampicin 600 mg PO BD Chloramphenicol 100mg/kg/day IV in 4 divided doses (contact Microbiology - max dose 4-6g/day) + Vancomycin mg IV QDS Page 7 of 14

8 GASTRO-INTESTINAL (Assumes non-pregnant, normal renal/hepatic function) Mild diverticulitis, Drained peri-rectal abscess Duration: 7-10 days Moderate/severe Diverticulitis, Non-drained perirectal abscess Campylobacter Duration: 5 days Non-typhoidal Salmonella, Shigella Traveler s diarrhoea Biliary tract infections Spontaneous bacterial peritonitis If culture positive, treat for up to 14days Co-trimoxazole 960mg BD PO + Metronidazole 500mg TDS PO If <65years: Co-amoxiclav 625mg TDS PO Amoxicillin 1g IV TDS + Gentamicin** 5mg/kg (max 500mg) IV + Metronidazole 500mg IV TDS If four quadrant peritonitis or patient unstable: Piperacillin/Tazobactam 4.5g TDS IV + Gentamicin** 5mg/kg (max 500mg) IV Usually resolves spontaneously. If severe or prolonged: Erythromycin 500mg BD PO Ertapenem 1g OD IV Ciprofloxacin mg BD PO + Metronidazole 500mg TDS PO 70kg: 600mg IV for 3 loading doses 12 doses 12 + Gentamicin** 5mg/kg (max 500mg) IV + Metronidazole IV 500mg TDS Usually resolves spontaneously. If severe/prolonged/immunocompromised host: Ciprofloxacin 500mg BD PO. Duration: Shigella: 3 days, Salmonella: 5-7 days (10-14 if immunocompromised) For Latin America & Africa Ciprofloxacin mg BD PO for 3 days Levofloxacin 500mg PO STAT For S. E. Asia and elsewhere: Azithromycin 1g PO STAT 500mg PO OD for 3 days Amoxicillin 1g IV TDS + Gentamicin** 5mg/kg (max 500mg) IV + Metronidazole 500mg IV TDS If cholangitis or patient unstable: Piperacillin/Tazobactam 4.5g TDS IV + Gentamicin** 5mg/kg (max 500mg) IV Piperacillin/Tazobactam 4.5g TDS IV If <65years: Co-amoxiclav 1.2g TDS IV Meropenem 1-2g IV TDS 70kg: 600mg IV for 3 loading doses 12 doses 12 + Gentamicin** 5mg/kg (max 500mg) IV + Metronidazole 500mg TDS IV Cefotaxime 1g BD IV Aztreonam 1g TDS IV + 70kg: 600mg IV for 3 loading doses 12 doses 12 Helicobacter pylori eradication Lansoprazole 30mg BD PO + Clarithromycin 500mg BD PO + Amoxicillin 1g BD PO Lansoprazole 30mg BD PO + Clarithromycin 500mg BD PO + Metronidazole 400mg BD PO Page 8 of 14

9 CLOSTRIDIUM DIFFICILE INFECTION (CDI) (Assumes non-pregnant, normal renal/hepatic function) In all cases discontinue other antibiotics if possible (or change to narrow spectrum/low risk) Loperamide (+ other anti-motility agents) are contraindicated. Mild to moderate CDI 3 loose stools (Bristol stool type 5 7) WCC normal Moderate CDI 4-6 loose stools (Bristol stool chart type 5 7) WBC elevated but <15 No response of Mild disease (after 6 days of continuous treatment) Pseudomembranous colitis /Severe colitis WCC > 15 Creatinine rise (>50% baseline) Temperature > 38.5 severe colitis Partial ileus Life threatening CDI Hypotension Partial/complete ileus Toxic megacolon Duration: days Metronidazole 400mg TDS PO Duration: 14 days Vancomycin 125mg QDS PO Duration: 10 days Vancomycin 250 mg QDS PO/NG (Vancomycin Injection may be given orally/ng) Duration: days Inform Microbiology & obtain early surgical review of all severe cases. Oral/NG Vancomycin 500 mg qds + Metronidazole 500 mg TDS IV + Vancomycin retention enemas: Vancomycin 500mg in 100ml of normal saline every 4-12 hours (retain for 60min) via Foley catheter or Flexiseal device. Insert 18-inch Foley catheter with a 30ml balloon into rectum (or Flexiseal device), inflate balloon and instil enema, clamp catheter then deflate balloon, and remove catheter and balloon Consider IV Immunoglobulin 400mg/kg C. difficile Risk of Common Antibiotics Low risk agents should be used when a patient is at risk of Clostridium difficile: this includes patients who have required multiple courses of antibiotics during the last 3 months. This list is not complete; please contact Microbiology or the Antimicrobial Pharmacist for risks associated with other agents. High risk Medium risk Low risk All Cephalosporins Amp/Amoxi-cillin Aminoglycosides Clindamycin Cotrimoxazole (Septrin) Metronidazole Quinolones All macrolides Vancomycin Tetracyclines Piperacillin/Tazobactam Co-amoxiclav Rifampicin Carbapenems Page 9 of 14

10 Respiratory (Assumes non-pregnant, normal renal/hepatic function) CURB-65 score 1 point for each C= Confusion (new AMT <8) U= Urea >7mmol/L R= Resp. rate 30/min B= Hypotension (SBP<90mmHg or DBP 60mmHg 65= Age 65 Low severity CAP CURB65 = 0-1 Or CRB score = 0 Antibiotics to be given within 4 hours Moderate severity CAP CURB65 = 2 Antibiotics to be given within 4 hours High Severity CAP CURB65 = 3-5 Antibiotics to be given Immediately and then review Aspiration Pneumonia Initial lung damage largely consists of chemical pneumonitis and is not infective Secondary infection typically presents days after the aspiration Duration: 7-10 days Acute exacerbation of COPD H1N1 Swine flu Suspected/ confirmed Infection And suspected bacterial pneumonia Amoxicillin 500mg - 1g TDS PO Treated in community previously: + Clarithromycin 500mg BD PO Suspected Mycoplasma infection: Doxycycline 200mg PO loading dose, then 100mg BD PO Amoxicillin 500mg -1g TDS PO + Clarithromycin 500mg BD PO If oral route not possible Amoxicillin 1g TDS IV Benzylpenicillin 1.2g QDS IV + Clarithromycin 500mg BD IV Piperacillin/Tazobactam 4.5g TDS IV ( 65 Years) Co-amoxiclav 1.2g TDS IV (< 65 years) + Clarithromycin 500mg BD IV If septic shock: Consider adding in Gentamicin 5mg/kg (max 500mg) IV Co-amoxiclav 1.2g IV TDS (< 65 years) for 48hrs then switch to 625mg TDS PO Piperacillin/Tazobactam 4.5g IV TDS ( 65 Years) Doxycycline 200mg PO loading dose then 100mg BD PO Doxycycline 200mg PO loading dose, then 100mg BD PO If oral route not possible 70kg: 600mg IV for 3 loading doses 12 doses 12 + Clarithromycin 500mg BD IV 70kg: 600mg IV for 3 loading doses 12 doses 12 + Clarithromycin 500mg BD IV for 7 days Levofloxacin 500mg BD IV is an alternative particularly if Legionella infection suspected for days Meropenem 500mg-1g IV TDS Levofloxacin 500mg OD-BD IV/PO +/- Metronidazole 500mg IV TDS (If anaerobic cover required) Doxycycline 200mg STAT PO then 100mg BD PO for 5 days or 200mg OD for 5 days depending on severity and risk If Doxycycline contraindicated: Clarithromycin XL 500mg-1g OD PO for 5days. Doxycycline 200mg STAT PO then 100mg BD PO for 5 days or 200mg OD for 5-7 days if IV necessary: Co-amoxiclav 1.2g IV TDS + Oseltamivir (Tamiflu) 75mg PO BD for 5 days Clarithromycin 500mg PO BD for 5-7 days + Oseltamivir (Tamiflu) 75mg PO BD for 5 days Page 10 of 14

11 Respiratory (Assumes non-pregnant, normal renal/hepatic function) CURB-65 score 1 point for each C= Confusion (new AMT <8) U= Urea >7mmol/L R= Resp. rate 30/min B= Hypotension (SBP<90mmHg or DBP 60mmHg 65= Age 65 HAP Non-severe/ early (in-patient 4days) Duration: 5-7 days and then review HAP Severe /late (in-patient 5days) and then review. VAP Early/ Nonsevere (in-patient 4days) Antibiotics should be commenced within 1 hour of diagnosis Treat for 7 days VAP Late onset/ Severe (in-patient 5days) Early VAP + risk factors Antibiotics should be commenced within 1 hour of diagnosis Treat for 7 days then review 65years or recent antibiotic treatment: Piperacillin/Tazobactam 4.5g IV TDS <65years: Co-amoxiclav 1.2g TDS IV Meropenem 1g IV TDS If MRSA positive add: 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 hours apart then OD Piperacillin/Tazobactam 4.5g IV TDS If MRSA positive and non-severe: +Doxycycline 200mg STAT PO then 100mg PO BD for 5-7 days (if sensitive). If IV required: use 70kg: 600mg IV for 3 loading doses 12 doses 12 If MRSA positive or cavitation on CXR: + Rifampicin 300mg BD IV/PO Meropenem 1g IV TDS If MRSA positive or suspected add: 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 hours apart then OD +/- Rifampicin 300mg BD IV/PO if cavitation on CXR Review with a Microbiologist within 24hrs Meropenem 500mg -1g IV TDS 70kg: 600mg IV for 3 loading doses 12 doses 12 + Gentamicin** 5mg/kg (max 500mg) IV Aztreonam 1g IV TDS 70kg: 600mg IV for 3 loading doses 12 doses 12 + Gentamicin** 5mg/kg (max 500mg) IV Aztreonam 1g IV TDS Meropenem 500mg -1g IV TDS 70kg: 600mg IV for 3 loading doses 12 doses 12 Aztreonam 1g IV TDS +/- Metronidazole 500mg TDS IV (if evidence of aspiration) 10mg/kg IV (max 800mg per dose) for 3 loading doses 12 Gentamicin** 5mg/kg (max 500mg) IV Aztreonam 1g IV TDS CONSIDER addition of Metronidazole 500mg TDS IV (if evidence of aspiration) Review with a Microbiologist within 24hrs Page 11 of 14

12 SOFT TISSUE (Assumes non-pregnant, normal renal/hepatic function) If MRSA suspected contact microbiology. Cellulitis: Localised / Mild Cellulitis: Moderate infection / hospital treatment Cellulitis: Severe Discuss length of treatment with Microbiology Necrotising fasciitis: Upper limb, head and neck Necrotising fasciitis: Lower limb, abdomen or perineum Diabetic foot infections & cellulitis: Superficial skin & soft tissue Diabetic foot infections & cellulitis: Complicated/ deep skin & soft tissue infection / sepsis Herpes Zoster (shingles) Mild post-operative wound infection Serious post-op wound infection: clean procedure Serious post-op wound infection: Clean/Contaminated procedure Human and animal bites Flucloxacillin 0.5-1g QDS PO total Benzylpenicillin 1.2g QDS IV + Flucloxacillin 1g QDS IV Benzylpenicillin g QDS IV + Flucloxacillin 2g QDS IV Flucloxacillin 1-2g IV QDS + Benzylpenicillin g IV 4-6 hourly + Clindamycin 900g - 1.2g IV QDS Consider IVIg Meropenem 2g every 8 hours IV + Clindamycin 900mg 1.2g every 6 hours IV Consider IVIg Flucloxacillin 1g PO QDS If offensive: + Metronidazole 400mg PO TDS Duration: 7-10days Piperacillin/Tazobactam 4.5g TDS IV ( 65years) Co-amoxiclav 1.2g TDS IV (< 65years) Clarithromycin 500mg BD PO Clarithromycin 500mg PO/IV BD Clindamycin 450mg PO QDS Daptomycin^ 4 6 mg/kg IV OD Linezolid 600mg IV/PO BD Not severe allergy: Clindamycin 900mg - 1.2g IV QDS + Meropenem 2g every 8 hours IV + Daptomycin^ 4 6 mg/kg IV OD Contact Microbiology for advice Consider IVIg Clindamycin 450mg PO QDS Clindamycin 600mg QDS IV (or 450mg QDS PO) + Ciprofloxacin 500mg BD PO Benefit only if treatment started within 3 days of onset of rash Valaciclovir 1g PO TDS for 7 days Aciclovir 800mg PO 5 times a day for 7 10 days Flucloxacillin 1g IV QDS Clindamycin 450mg every 6 hours PO Flucloxacillin 1-2g IV QDS Piperacillin/Tazobactam 4.5g TDS IV ( 65years) Co-amoxiclav 1.2g TDS IV (< 65years) Co-amoxiclav 625mg TDS PO Duration: 5-7 days 70kg: 600mg IV for 3 loading doses 12 doses 12 Meropenem 500mg-1g IV TDS 70kg: 600mg IV for 3 loading doses 12 doses 12 Doxycycline 200mg stat then 100mg PO BD + Metronidazole 400mg PO TDS Clindamycin 450mg PO QDS + Ciprofloxacin 500mg PO BD Page 12 of 14

13 URINARY TRACT (Assumes NON-PREGNANT, normal renal/hepatic function) Asymptomatic bacteriuria Recurrent (uncomplicated) UTI in women Female lower urinary tract infection (uncomplicated) Duration: 3 days Male lower urinary tract infection Prostatitis/ epididymo-orchitis Pyelonephritis, Hospital acquired, recurrent UTI complicated No treatment is required unless there is a specific indication e.g. pregnancy, outflow obstructions, diabetic, renal scarring Nitrofurantoin 50mg NOCTE Trimethoprim 100mg NOCTE Trimethoprim 200mg BD PO Nitrofurantoin mg QDS PO If ESBL isolated: Nitrofurantoin mg qds PO (if sensitive) for 7 days may be effective in uncomplicated lower UTI Trimethoprim 200mg BD PO If ESBL isolated Nitrofurantoin mg qds PO (if sensitive) for 7 days may be effective in uncomplicated lower UTI If ESBL and prostatic involvement suspected or resistance to Nitrofurantoin: discuss with Microbiologist If prostatic involvement (especially if failure to respond): Ciprofloxacin 500 mg bd PO for 3-4 weeks. Ciprofloxacin 500mg every 12 hours PO Duration: 3-4 weeks in total (may need longer for chronic infections). If orchitis was part of presentation or cannot be excluded then give for 4 weeks. Piperacillin/Tazobactam 4.5g TDS IV If evidence of severe sepsis: + Gentamicin** 5mg/kg (max 500mg) IV and review with culture results. Gentamicin** 5mg/kg (max 500mg) IV and review with culture results Catheter associated Treat for 7 days in total Extended spectrum betalactamase (ESBL) UTI Duration: 14 days in total Piperacillin/Tazobactam 4.5g TDS IV If evidence of severe sepsis: + Gentamicin** 5mg/kg (max 500mg) IV and review with culture results. Nitrofurantoin mg qds (if sensitive) for 7 days may be effective in uncomplicated lower UTI with ESBL. If suspected ESBL UTI with systemic sepsis or upper ESBL: Ertapenem 1g OD IV for 7 days. Gentamicin** 5mg/kg (max 500mg) IV and review with culture results Contact Consultant Microbiologist Page 13 of 14

14 Penicillin Allergy Life-threatening adverse reactions to penicillins due to immediate hypersensitivity (IgE mediated) are rare. A reliable history is key. Patients with a history of clinical signs of Type I immediate hypersensitivity are at increased risk of immediate hypersensitivity to Penicillins and should not receive Beta-lactam antibiotics. Drugs in RED are contra-indicated Drugs in ANGE are NOT for use in patients with a serious Penicillin allergy & use with caution in patients with a history of minor allergic symptoms. Drugs in GREEN are considered safe Characteristics Timing of onset Clinical signs Type I immediate hypersensitivity reactions 1 to 4 hours from exposure (up to 72 hours) Anaphylaxis Laryngeal oedema Wheezing / bronchospasm Angioedema Urticaria / pruritis Diffuse erythema Non-Type I reactions (Types II-IV and idiosyncratic) >72 hours from exposure Maculopapular rash Morbilliform rash RBCs / platelets Drug fever (serum sickness) Tissue injury (immune complex) Contact dermatitis Key High risk agent for Clostridium difficile diarrhoea (Co-amoxiclav in elderly is high risk) ** Patients with impaired renal function CrCl < 60 ml/min (Cockcroft-Gault) use a reduced dose of 3mg/kg. Dosing is based on actual body weight (ABW) unless patient is obese (20% over ideal body weight (IBW)) Obese dosing weight= IBW (ABW-IBW). Males: IBW=50kg + 1kg for every cm over 150cm height Females: IBW=45kg + 1kg for every cm over 150cm height ^ Rhabdomyolysis has been reported, monitor CPK weekly during treatment Linezolid can cause myelosuppression, monitor FBC baseline and weekly. Page 14 of 14