Empirical Management of Infection on Critical Care Units at AUH and RLUH

Transcription

1 LIVERPOOL CLINICAL LABORATORIES Empirical Management of Infection on Critical Care Units at AUH and RLUH Patricia Crossey (Critical Care Pharmacist, RLUH), Alison Hall (ITU Consultant, RLUH), Jenifer Mason (Microbiology Consultant LCL), Robert Parker (ITU Consultant, AUH) and Clare Sales (Critical Care Pharmacist, AUH) 207 These Guidelines refer to common ITU presentations and relate to empirical management only. For indications not covered refer to the Trust Antibiotic Formulary (Royal and Aintree). Enquiries to: or

2 Contents General Principles... 2 Abdominal Infection... 3 Non Healthcare associated Intra-abdominal Infection... 3 Healthcare associated intra-abdominal infection... 4 Variceal bleeds and acute liver failure... 4 Central Nervous System... 5 Meningitis/Encephalitis... 5 ENT or Dental Infection... 6 Epiglottitis... 6 Dental Abscess or other oral infection... 6 Respiratory Tract Infection... 7 Community acquired pneumonia... 7 Hospital Acquired Pneumonia or Ventilator Associated Pneumonia... 7 Aspiration Pneumonia... 8 Infective Exacerbation of Chronic Lung Disease (COPD, bronchiectasis)... 8 Suspected influenza with concurrent pneumonia... 8 Sepsis of Unknown Origin... 9 Sepsis of Unknown Origin Non Neutropenic... 9 Neutropenic Sepsis... 9 Skin and Soft Tissue Infection... 0 Necrotising soft tissue infection of any anatomical site... 0 Cellulitis... 0 Trauma Prophylaxis... Prophylaxis in head and neck trauma... Prophylaxis for Compound Fractures... Selective Decontamination of the Digestive Tract... Error! Bookmark not defined. Urosepsis... 3 Urosepsis/pyelonephritis... 3 Appendix... 4 Infection Control Precautions... 4 Weekly Screening... 5 Notifiable Diseases... 7 Tetanus Prone Wounds... 8 Processing Urgent Specimens Out of Hours (Mon-Fri and Sat-Sun)... 9 Gentamicin and Teicoplanin Dosing... 2 Gentamicin... 2 Teicoplanin... 2 Contact Details... 2 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page

3 General Principles. Antibiotic treatment should NEVER be delayed in an emergency. However, wherever possible, microbiological specimens should always be obtained before antibiotic therapy is commenced 2. Prior to antibiotic therapy patients should ALWAYS have TWO sets of blood cultures taken i.e. x2 aerobic and x2 anaerobic bottles. If there are lines present culture from the line AND a peripheral site. Send other specimens as appropriate (respiratory, drain fluid, wound swabs etc.) 3. Always check previous Microbiology results, with particular attention to resistant organisms (see below for common resistance patterns). Note the empirical antibiotic choice may not cover resistant organisms please discuss with Microbiology if unsure 4. Antibiotics are not a substitute for source control (i.e. surgical drainage of an abscess) 5. Antibiotics should be administered within hour in patients with signs of severe sepsis or septic shock 6. Allergy status must be checked BEFORE prescribing and administering any antibiotic and documented on the patient s drug chart, including where possible the nature of the allergy 7. An antibiotic history should be taken and recorded in the critical care notes 8. All antibiotic prescriptions should have an indication, start date and review or stop date. 9. These guidelines are for empirical management only. Antibiotics should be focussed at the earliest opportunity on the Microbiology ward round with culture results 0. Do not dose adjust antibiotics in acute kidney injury (including Gentamicin) in the first 24 hours. Following this, and in chronic renal failure seek advice from Pharmacy Methicillin resistant Staphylococcus aureus (MRSA) Vancomycin or glycopeptide resistant Enterococci (VRE or GRE) Extended spectrum beta-lactamase producing Enterobacteriaceae AND/OR de-repressed AmpCs (ESBL/AmpC) Carbapenemase producing Enterobacteriaceae (CPE) Not effective May be effective Effective Penicillin, flucloxacillin, Clarithromycin or co-amoxiclav, tazocin, clindamycin, cephalosporins (except doxycycline, ceftaroline) trimethoprim meropenem Amoxicillin, teicoplanin, tazocin, cephalosporins, meropenem, aminoglycosides, fluoroquinolones Tazocin, co-amoxiclav, cephalosporins, Aztreonam Tazocin, co-amoxiclav, cephalosporins, meropenem (in isolation) Aminoglycosides, fluoroquinolones, tigecycline, temocillin Fluoroquinolones, aminoglycosides, temocillin, high-dose meropenem (in combination), chloramphenicol, tigecycline, colistin Teicoplanin, linezolid, daptomycin Linezolid, tigecycline, daptomycin Meropenem, ertapenem Always discuss management of suspected CPE infection with an infection specialist For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 2

4 Abdominal Infection Non Healthcare associated Intraabdominal Infection Infection involving ANY intra-abdominal organ (with the exception of kidney) without any of the following:. Infection arising >48 hours after admission 2. Presence of invasive surgical device at time of presentation (e.g. biliary stent) 3. History of infection or colonisation with multi-drug resistant organism (MRSA, VRE, ESBL, CPE) 4. History of surgery, hospitalisation or dialysis within 2 months of presentation Empirical Antibiotics are NOT required in: Acute-Severe Pancreatitis: Antibiotics are not recommended in the acute phase. In chronic pancreatitis discuss management of all patients with Microbiology. Bowel ischaemia with no evidence of perforation/peritoneal contamination Acute gastroenteritis: Antibiotics may be indicated for invasive Salmonella, Shigella or Campylobacter infection discuss all cases with Microbiology. Investigations Blood cultures Intra-operative specimens where appropriate Recommended Amoxicillin g QDS IV, Metronidazole 500mg TDS IV & regular Gentamicin IV For oesophageal perforation also include Fluconazole 400mg IV Alternative (penicillin Teicoplanin IV, regular Gentamicin IV & Metronidazole 500mg TDS IV For oesophageal perforation also include Fluconazole 400mg IV Duration: In most cases 5-7 days will suffice following complete source control. Postsurgery: No bacterial contamination of operative field or peritoneum: Consider stopping antibiotics (discuss with Microbiology) Bacterial contamination of operative field or peritoneum: 5-7 days from definitive operative procedure Antifungals: With the exception of oesophageal perforation, prophylactic antifungals are not recommended in non-neutropenic ITU patients. Preemptive antifungals or targeted therapy to be discussed with Microbiology on individual patient basis For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 3

5 Healthcare associated intraabdominal infection Infection involving ANY intra-abdominal organ (with the exception of kidney) with at least one of the following:. Infection arising >48 hours after admission 2. Presence of invasive device at time of presentation (e.g. biliary stent) 3. History of infection or colonisation with multi-drug resistant organism (MRSA, VRE, ESBL, CPE) 4. History of surgery, hospitalisation or dialysis within 2 months of presentation For C. difficile treatments refer to Trust C. difficile policy. Empirical Antibiotics are NOT required in: Acute-Severe Pancreatitis: Antibiotics are not recommended in the acute phase. In chronic pancreatitis discuss management of all patients with Microbiology. Bowel ischaemia with no evidence of perforation/peritoneal contamination Acute gastroenteritis: Antibiotics may be indicated for invasive Salmonella, Shigella or Campylobacter infection if invasive infection suspected (recent travel, immunocompromised host) discuss with Microbiology Investigations Blood cultures Intra-operative specimens where appropriate Recommended Tigecycline 00mg STAT then 50mg BD IV & regular Gentamicin IV For oesophageal perforation also include Fluconazole 400mg OD IV Alternative (penicillin Tigecycline 00mg stat, 50mg BD IV & regular Gentamicin IV For oesophageal perforation also include Fluconazole 400mg OD IV Duration: In most cases 5-7 days will suffice following complete source control. Post-surgery: No bacterial contamination of operative field or peritoneum: Consider stopping antibiotics (discuss with Microbiology) Bacterial contamination of operative field or peritoneum: 5-7 days from definitive operative procedure Tigecycline: Tigecycline is not safe to use in indications other than intraabdominal infection. If concurrent infection (such as pneumonia) discuss with Microbiology Antifungals: With the exception of oesophageal perforation, prophylactic antifungals are not recommended in non-neutropenic ITU patients. Preemptive antifungals or targeted therapy to be discussed with Microbiology on individual patient basis Variceal bleeds and acute liver failure Investigations Recommended Tazocin 4.5g TDS BD IV For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 4

6 Alternative (penicillin Ciprofloxacin 400mg BD IV Further advice can be sought from Hepatology or Birmingham Transplant Unit If signs of sepsis: Include regular Gentamicin Central Nervous System Meningitis/Encephalitis This is a Notifiable Disease see appendix Additional infection prevention precautions are required for suspected meningitis see appendix Investigations Blood cultures EDTA blood for meningococcal and pneumococcal PCR CSF: For MC&S and viral PCR +/- meningococcal and pneumococcal PCR, protein and glucose Urine pneumococcal antigen HIV test Recommended Ceftriaxone 2g BD IV AND Acyclovir 0mg/kg IV TDS IV & Dexamethasone IV or PO* If aged over 60 or immunosuppressed: Add Amoxicillin 2g IV every 4 hours Alternative (penicillin Chloramphenicol 25mg/kg QDS IV + Acyclovir 0mg/kg TDS IV & IV Dexamethasone IV or PO* If aged over 60 of immunosuppressed: Add Cotrimoxazole 30mg/kg IV every 6 hours If recent history of travel please discuss with Microbiology *Give IV dexamethasone 0mg QDS IV or PO for 4 days preferably prior to or at the same time as the first dose of antibiotics (if administration delayed dexamethasone may be given up to 2 hours after first dose of antibiotic). Note: Dexamethasone vials contain either 3.3mg or 3.8mg of Dexamethasone depending on the supplier. Suggest using either 9.9mg (3x3.3mg vials) or 9.5mg (2.5x3.8mg vials). Contact Occupation Health and/or Microbiology regarding prophylaxis for staff members exposed to N. meningitidis For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 5

7 ENT or Dental Infection Epiglottitis Investigations Throat swab for MC&S Blood cultures Recommended Ceftriaxone 2g OD IV Alternative (penicillin Teicoplanin + Ciprofloxacin 400mg BD IV Dental Abscess or other oral infection If necrotising intra-oral or neck infection suspected contact Microbiology Investigations Blood cultures Intra-operative samples Recommended Amoxicillin g QDS IV + Metronidazole 500mg TDS IV Alternative (penicillin Clarithromycin 500mg BD IV & Metronidazole 500mg TDS IV If necrotising intra-oral or neck infection suspected contact Microbiology For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 6

8 Respiratory Tract Infection Community acquired pneumonia Suggested Investigations Onset <48 hours of admission Blood cultures x 2 Respiratory specimen: BAL>T/asp>sputum Urinary Legionella and pneumococcal antigen HIV test Within flu season (approx. October March) throat swab for viral PCR Recommended Alternative (penicillin Acute and convalescent sera for atypical pathogens is no longer recommended Benzyl-penicillin 2.4g QDS IV & Clarithromycin 500mg BD PO/IV Teicoplanin IV & Clarithromycin 500mg BD PO/IV If signs of severe sepsis or septic shock, or the diagnosis of pneumonia is unclear: STAT Gentamicin A negative Legionella urinary antigen result does not exclude atypical infection. Continue clarithromycin pending discussion on Microbiology. Assess response to empirical therapy with a Microbiologist at hours. If no response or deterioration consideration should be given to changing antibiotics. Gram negative, in particular anti-pseudomonal cover should be included in patients with structural lung disease (bronchiectasis, CF, long term ventilator). If no prior exposure use ciprofloxacin as an alternative to clarithromycin. Hospital Acquired Pneumonia or Ventilator Associated Pneumonia Pneumonia acquired >48 hours of admission to hospital or ventilated patients Investigations Blood cultures Respiratory specimen: BAL>T/asp>sputum Recommended Benzyl-penicillin 2.4g QDS IV & Flucloxacillin 2g QDS IV & Ciprofloxacin 500mg BD PO or 400mg BD IV If signs of severe sepsis or septic shock: STAT Gentamicin IV If MRSA colonised: Teicoplanin IV & Ciprofloxacin 500mg BD PO or 400mg BD IV For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 7

9 Alternative (penicillin Aspiration Pneumonia If colonised with CPE: discuss with Microbiology Teicoplanin IV & Ciprofloxacin 500mg BD PO or 400mg BD IV If signs of severe sepsis or septic shock: STAT Gentamicin If colonised with a CPE: discuss with Microbiology History compatible with aspiration AND signs or symptoms of pneumonia AND minimum of 48 hours post aspiration event. Aspiration of gastric contents or pneumonitis alone is not an indication for antibiotics Investigations Blood cultures Respiratory samples Recommended Temocillin 2g BD IV & Amoxicillin g QDS IV & Metronidazole 500mg TDS IV Alternative (penicillin Ciprofloxacin 400mg BD IV, Clarithromycin 500mg BD IV & Metronidazole 500mg TDS IV Infective Exacerbation of Chronic Lung Disease (COPD, bronchiectasis) Check previous respiratory samples patients with chronic lung disease become colonised with resistant Pseudomonas species. Investigations Blood cultures Respiratory samples Recommended Benzyl-penicillin 2.4g QDS IV & Ciprofloxacin 500mg BD PO or 400mg BD IV Alternative (penicillin Teicoplanin & Ciprofloxacin 500mg BD PO or 400mg BD IV In the case of recent Ciprofloxacin exposure (within the preceding 4-6 weeks): Discuss alternative agent with Microbiology If signs of severe sepsis or septic shock: STAT Gentamicin Suspected influenza with concurrent pneumonia Influenza like illness with clinical features of pneumonia Additional infection prevention precautions are required for suspected influenza see appendix Investigations Blood cultures Respiratory samples Throat swab and viral PCR Recommended Benzyl-penicillin 2.4g QDS IV & Clarithromycin 500mg BD PO/IV & Flucloxacillin 2g QDS IV & Oseltamivir 75mg BD PO Alternative (penicillin Teicoplanin IV & Clarithromycin 500mg BD PO/IV & Oseltamivir 75mg BD PO For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 8

10 If signs of severe sepsis or septic shock: STAT Gentamicin Sepsis of Unknown Origin Sepsis of Unknown Origin Non Neutropenic Sepsis with no identifiable source. Review with Microbiology at 48 hours is mandatory. Investigations Blood cultures (including line cultures if appropriate) Any other appropriate investigations: Wounds, CSU, CSF, respiratory Recommended Tazocin 4.5g TDS & STAT Gentamicin IV Alternative (penicillin Teicoplanin IV & Gentamicin IV & Metronidazole 500mg TDS IV Review at 48 hours with Microbiology is mandatory Neutropenic Sepsis Investigations Blood cultures (including line cultures if appropriate) Any other appropriate investigations: Wounds, CSU, CSF, respiratory Recommended Tazocin 4.5g TDS IV & STAT Gentamicin IV Alternative (penicillin see notes below If pulmonary focus: Add Clarithromycin 500mg BD PO/IV If MRSA positive or indwelling line: Add Teicoplanin IV If colonised with ESBL or AmpC: Give Meropenem 2g TDS IV If colonised with CPE: Discuss with Microbiology Meropenem 2g TDS IV If pulmonary focus: Add Clarithromycin 500mg BD PO/IV If MRSA positive or indwelling line: Add Teicoplanin IV If colonised with ESBL or AmpC: Give Meropenem 2g TDS IV If colonised with CPE: Discuss with Microbiology Severe penicillin allergy i.e. anaphylaxis: Discuss risk/benefit ratio It is estimated that <% of patients with penicillin allergy react to carbapenems. In severe penicillin allergy (i.e. anaphylaxis) discuss risks and benefits of carbapenem with Microbiology For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 9

11 Skin and Soft Tissue Infection Necrotising soft tissue infection of any anatomical site All cases must be referred to Surgical team and discussed with Microbiology urgently This is a Notifiable Disease - see appendix Additional infection prevention precautions are required for suspected invasive Group A streptococcal infections see appendix Investigations Blood cultures Intra-operative specimens (Urgent Gram stain required) Wound swabs Recommended Meropenem 2g IV TDS & Clindamycin.2g QDS IV 8 hours +/- IVIG (discuss with Microbiology) Alternative (penicillin Meropenem 2g IV TDS & Clindamycin.2g QDS IV 8 hours +/- IVIG 2g/kg (IVIG administration MUST be discussed with Microbiology) Surgical debridement is imperative. Refer all patients to the Surgical Team urgently For details regarding IVIG administration refer to IVIG Policy Cellulitis Localised cellulitis with no features of necrotising infection Investigations Blood cultures x2 Skin/wound swab Recommended Flucloxacillin 2g QDS IV Alternative (penicillin Teicoplanin IV & Clindamycin 300 QDS If high risk of C. difficile: Use Linezolid 600mg BD IV/PO instead of above For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 0

12 Trauma Prophylaxis Prophylaxis in head and neck trauma Prophylaxis is indicated for compound mandibular fractures, soft tissue pre-septal trauma, penetrating orbital injury and pharyngealoesophageal injury. Please refer to Antimicrobial Guidelines for Head and Neck Surgery for further information All wounds should have a tetanus risk assessment see appendix Investigations Recommended Compound Mandibular Fractures: Chlorhexidine gluconate 0.5% mouthwash BD & Amoxicillin g TDS IV & Metronidazole 500mg TDS IV until operation. Soft Tissue pre-septal trauma: IV Flucloxacillin 2g QDS & topical Chloramphenicol % ointment TDS Penetrating Orbital Injury: Tazocin 4.5g TDS IV Pharyngeal-oesophageal Injury: Tazocin 4.5g TDS IV (& Teicoplanin IV if colonised with MRSA) Alternative (penicillin Compound Mandibular Fractures: Chlorhexidine gluconate 0.5% mouthwash BD & Clarithromycin 500mg BD IV & Metronidazole 400mg TDS IV until operation Soft Tissue pre-septal trauma: IV Clarithromycin 500mg BD IV & topical Chloramphenicol % ointment TDS Penetrating Orbital Injury: Teicoplanin IV & Ciprofloxacin 750mg BD IV & Metronidazole 500mg TDS IV Pharyngeal-oesophageal Injury: Teicoplanin IV & Ciprofloxacin 750mg BD IV & Metronidazole 500mg TDS IV Prophylaxis for Compound Fractures Investigations Recommended All wounds should have a tetanus risk assessment see appendix Co-amoxiclav.2g IV (alone) TDS, OR Cefuroxime.5g IV every 8 hours plus Metronidazole 500mg IV every 8 hours MRSA colonised: Add Teicoplanin 800mg IV 2 hourly for 3 doses DURATION: 48 hours or 24 hours post closure of wound For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page

13 Alternative (penicillin Clindamycin 600mg IV QDS. Gunshot Injury or very extensive or contaminated wound: Add Ciprofloxacin 400mg IV TDS (or PO 750mg BD) MRSA colonised: Add Teicoplanin 800mg IV BD for 3 doses DURATION: 48 hours or 24 hours post closure of wound For tetanus guidance see appendix For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 2

14 Urosepsis Urosepsis/pyelonephritis Sepsis with features in the history or examination that clearly indicate a renal source. If source of infection is unclear treat as sepsis or unknown origin Investigations Blood cultures MSU or CSU Recommended Ciprofloxacin 400mg IV BD + STAT Gentamicin IV Alternative (penicillin Ciprofloxacin 400mg IV BD + STAT Gentamicin IV Dipstick has poor positive and negative predictive value and should not be used in isolation to diagnose UTI. For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 3

15 Appendix Infection Control Precautions Standard precautions should be used for all patients (hand-washing, personal protective equipment for procedures etc.). Additional precautions required in specific scenarios are outlined below. There are times when side room availability is limited in this situation a risk assessment should be conducted according to local policy. Additional support available if required from IP&C Teams and Microbiology. Isolation Isolation Area PPE Required MRSA Yes Isolation room Plastic apron and gloves VRE/GRE Yes (priority if diarrhoea present) Priority for patients with diarrhoea and uncontrolled leakage of body fluids Plastic apron and gloves ESBL or AmpC Yes (priority if diarrhoea present) Priority for patients with diarrhoea and uncontrolled leakage of body fluids Plastic aprons and gloves Clostridium Yes Isolation room Plastic aprons and gloves difficile infection + GDH positive CPE Yes Isolation room Surgical gown and gloves Influenza Yes Isolation room Surgical gown and surgical mask Suspected or proven invasive Group A streptococcus Suspected bacterial meningitis Yes for minimum 48 hours after commencing appropriate antibiotic(s) Yes review at 48 hours with Microbiology results Isolation room Isolation room For aerosol generating procedures use FFP3 mask Plastic aprons and gloves For aerosol generating procedures including intubation use FFP3 mask Plastic apron and gloves For aerosol generating procedures including intubation use FFP3 mask Neutropenic Yes Isolation room Plastic apron and gloves Inter-Hospital Transfer pending screen results Yes Isolation room Plastic apron and gloves For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 4

16 Weekly Screening Patients on ITU should have a multidrug resistant organism (MDRO) screen (rectal & groin AND nose & throat) for ESBL, AmpC, MRSA, VRE and CPE colonisation on admission and weekly thereafter. Transfers It is essential that MDRO colonisation status from referring Trust is ascertained prior to transfer. Refer to local policy regarding isolation. In patients transferred from Aintree ITU, Royal ITU or HDU, Liverpool Heart and Chest ITU or Walton Centre Horsley ITU consideration may be given to early removal from side room - discuss with Microbiology or IP&C Team. For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 5

17 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 6

18 Notifiable Diseases Treating clinicians have a statutory duty to notify the proper officer at their local council or local health protection team (HPT) of suspected cases of certain infectious diseases. Notifiable organisms will be reported by the laboratory. To inform Cheshire and Merseyside Health Protection Team: Mon-Fri : (option ) Mon-Fri or Sat-Sun: Contact the on-call Public Health Doctor via Switch Board at the Royal ( ) The list below gives common notifiable diseases and is not exhaustive. Please see Health Protection England website for complete list. Notifiable Disease Definition/Comment Likely to be Urgent? Acute encephalitis No Acute meningitis Viral and bacterial Yes, if bacterial meningitis suspected Acute hepatitis Yes Anthrax Suspect in heroin user with severe sepsis, necrotising skin infection or meningitis (especially haemorrhagic meningitis). Yes Enteric fever (S. typhoid or paratyphoid) Food poisoning Haemolytic uraemic syndrome Typical skin lesion = Painless ulcer with marked oedema and black eschar Fever, constipation, rose spots and recent travel Triad of acute renal failure, microangiopathic haemolytic anaemia, and non-immune thrombocytopenia following bloody diarrhoea Infectious bloody diarrhoea With or without features of HUS Yes Necrotising fasciitis (likely to be invasive Group A Streptococcus i.e. in PWID) Scarlett Fever or suspected invasive infection (i.e. bacteraemia, necrotising fasciitis or septic arthritis) Legionnaires Disease Meningococcal septicaemia SARS Tetanus Tuberculosis Pneumonia (usually with extra-pulmonary signs such as headache, abdominal pain, renal failure) AND history of exposure (i.e. cooler units, water, air conditioning, travel history) Without meningitis for example sepsis with purpuric rash Rigidity, muscle spasm and autonomic dysfunction with history of tetanus prone wound or injecting drug use. Clinical picture in keeping with TB and AFB on sputum smear Yes No unless associated with a cluster or outbreak Yes Scarlet Fever no Invasive Group A Streptococcal infection Yes Yes Yes Yes Only if associated with injecting drug use No unless suspected cluster, multidrug resistance or healthcare worker For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 7

19 Tetanus Prone Wounds A tetanus prone wound is any wound or burn that requires a surgical intervention or when treatment is delayed for more than 6 hrs, or wounds with any of the following characteristics: o o o o significant degree of devitalized tissue, puncture-type injury (particularly in contact with soil or manure), wounds containing foreign bodies, compound fractures, wounds or burns in patients who have systemic sepsis. High risk wounds are those contaminated with material likely to contact tetanus spores i.e. soil, manure etc. If the wound or burn fulfils the above criteria and is considered to be high risk then tetanus immunoglobulin should be given for immediate protection irrespective of the tetanus immunization history. For further guidance see table below. Dose: For prevention: 250IU by intramuscular injection, or 500IU if more than 24 hours have elapsed since injury or there is a risk of heavy contamination or following burns. Clean Wound Tetanus Prone Wound Vaccine Vaccine Immunoglobulin Fully immunised, i.e. has received a total five doses of vaccine at appropriate intervals OR Protetanus Point of Care test demonstrates immunity Primary immunisation complete, boosters incomplete but up to date Not immunised or immunisation status not known or uncertain None required None required Only if high risk A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) An immediate dose of vaccine followed, if records confirm that is needed, by completion of a full 5-day dose course to ensure future immunity A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) An immediate dose of vaccine followed, if records confirm that is needed, by completion of a full 5 dose course to ensure future immunity Yes: one dose of human tetanus immunoglobulin in different site Yes: one dose of human tetanus immunoglobulin in different site For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 8

20 Processing Urgent Specimens Out of Hours (Mon-Fri and Sat-Sun) The following specimens will be processed urgently out of hours: CSF, joint aspirates, ascitic fluid, and tissue specimens in suspected necrotising fasciitis. Other specimens may be processed upon request. For urgent specimens taken out-of hours: ) Inform the On-call Microbiology Biomedical Scientist at Royal Liverpool University Hospital via Switch board ( ) 2) Specimen transport to Laboratory: a. For Royal ITU or HDU: Pod specimen to pod no. 70 b. For Aintree ITU: Take the specimen to Specimen Reception at Aintree (Ground floor of the main corridor, opposite A&E). The BMS will arrange transport to Liverpool Clinical Laboratories 3) The on-call BMS or Microbiologist will ring ITU with the result once processed For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 9

21 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 20

22 Gentamicin and Teicoplanin Dosing Gentamicin In normal renal function OR acute kidney injury: 5mg/kg STAT max 450mg. Teicoplanin In chronic renal failure: Discuss with Microbiology regarding alternative agents For regular Gentamicin administration: o Royal: Take level at 8 hours post dose and refer to the Gentamicin dosing calculator +/- seek advice from ITU Pharmacist regarding further dosing. o Aintree: Take a level at hour and 7 hours post dose (if not able to do these take 2 levels approximately 6 hours apart) and refer to the Gentamicin dosing calculator +/- seek advice from ITU Pharmacist regarding further dosing. Further information regarding Gentamicin dosing available on the Trust Intranet. Loading regime Days 2 Days 3 4 Day 5 onwards 2mg/kg BD (rounded to the nearest 200mg vial) 2mg/kg OD (rounded to the nearest 200mg vial) Take pre-dose (trough) level on day 4 Adjust dose according to renal function (see table 2) and review with levels Maintenance dose (based on renal function) egfr > 60ml/min egfr 30-60ml/min egfr< 30ml/min Haemodialysis Hemofiltration Continue 2mg/kg OD 6mg/kg OD 4mg/kg OD or 2mg/kg three times a week 2mg/kg three times a week after dialysis Load as per normal renal function Contact Details Microbiology (from RLUH) Ext. 440 Microbiology (from AUH) Ext Pharmacy at RLUH Ext Pharmacy at AUH Ext For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 2