GUIDELINES FOR ANTIMICROBIAL THERAPY

Transcription

1 GUIDELINES FOR ANTIMICROBIAL THERAPY Page 1 of 40

2 DOCUMENT DETAILS Document Title Document Number GUI/CL/WCN/987 Version Number 001 Replaces Antibiotic Policy Antimicrobial Policy Horsley ITU If new document, reason for development N/A Description of Amendments Re-write Document Type Guidelines Content Clinical Application WCNN Author/Originator and Title Jenny Sparrow, Pharmacy Date of Circulation October 2011 Document to be read in conjunction with Reference/s Ratifying Committee/s Drugs and Therapeutics Committee Ratified Date September 2011 Review Date September 2012 Person/s Responsible for Reviewing Pharmacy Department Document Training Required No Completed Distribution Information Page Yes Completed Training Information Page Yes Completed Equality & Diversity Screening Yes Completed Document Control Checklist Yes (chair of committee to sign only when ALL Document Control Pages have been completed) Name:. Date: Signature:. Document Change History - changes from previous issues of document (if applicable): Page Description of Changes Re-write Page 2 of 40

3 TABLE OF CONTENTS Foreword 5 General Comments and Advice 6 Basic Principles 6 i) Antibiotic Prescribing and Course Length Policy 6 ii) Restricted Anticicrobials 8 iii) Hospital and Community Acquired Infections 8 iv) Collection of Specimens 8 v) Urgent Treatment 9 vi) Antibiotic Assay Monitoring Policy Gentamicin/Vancomycin 9 Gentamicin 10 Vancomycin 11 vii) Topical Antimicrobials 11 viii) Hypersensitivity to Penicillins 11 ix) Impaired Renal and/or Hepatic Function 12 x) Antimicrobial/Antiviral use in Pregnancy and Breastfeeding 12 xi) Community IV Antibiotic Therapy Service (applies to infections marked *) 12 xii) Sources of Specific Advice 13 How to Contact Pharmacy 15 Standard Perioperative Prophylaxis for all Neurosurgical Procedures 16 General Principles 16 Guidelines 16 Conditions/Procedures when Prophylaxis is Not Required 16 Antibiotic Treatment Regimes for Specific Neurosurgical Infections 17 1) Bone Flap Infections/Osteomyelities * 2) Subdural Empyema * 3) Brain Abscess * 4) MRSA Brain Abscess/Subdural Empyema/Spinal Epidural Abscess 5) CSF Ventriculitis 6) Shunt Infections 7) * Paraspinal/Epidural Abscess 8) * Discitis 9) * Spinal Metal Work Infections 10) Brain Implant Infections 11) Penetrating Craniocerebral Injuries/Open Skull Fractures (non-operated) Page 3 of 40

4 Common Neurosurgical Management Issues 21 a) Pin Site/Halo Infections b) Post-Operative CSF Leaks c) CSF Sampling d) Extended Antibiotic Treatment Meningitis 22 Postoperative Neurosurgical Meningitits 23 Encephalitis 24 Pneumonia 25 Gastro-Intestinal Infections 27 Septicaemia 28 Urinary Tract Infections 30 Skin Infections 33 Tuberculosis (including non-pulmonary tuberculosis) 34 Treatment and Eradication of Methicilling Resistant Staphylococcus Aureus 35 (MRSA) Horlsey ITU/HDU Antimicrobial Policy 36 1) Lower Respiratory Tract Infections in ICU Patients 2) Intra-Abdominal Infections (peritonitis) 3) Peripheral Cannula Infections 4) Central Line Infections 5) Management of Candidiasis in ICU 6) Postoperative Meningitis 7) Septicaemia 8) Management of Bladder Associated Infection Appendix 1 Specific Anti-Tetanus Prophylaxis 40 Page 4 of 40

5 FOREWORD These Guidelines for Antimicrobial Therapy within The Walton Centre NHS Foundation Trust have been ratified by The Walton Centre Drugs and Therapeutics Group. It is the Trust s policy that these Guidelines should be adhered to unless advised otherwise by a Consultant Microbiologist. The guidelines are distributed to all wards, departments and medical staff. They are also available on the intranet and can be accessed via policies and procedures > infection control policies > antimicrobial guidelines. They complement the British National Formulary (BNF) recommendations on antibiotic usage. The BNF is itself electronically available on These guidelines are for the management of hospital-acquired infections, specialist neurological infections in hospitalised patients, and for when neurosurgical infection is suspected. The recommendations are for empirical antibiotic therapy in adults. The implementation of these guidelines is supported through a ward-based Pharmacy service and the Medical Microbiology Department at University Hospital Aintree (UHA) and trust wide collaborative antibiotic ward rounds. This third edition supersedes the January 2008 Edition. Next Review Date: September 2012 Contributing authors: Dr R Cooke, Consultant Medical Microbiologist - Chairman of the Antibiotic Action Group Dr. M Rothburn, Consultant Medical Microbiologist Dr P Lal, Consultant Medical Microbiologist Mr D Lawson Consultant Neurosurgeon Miss R Unsworth, Senior Pharmacist, The Walton Centre Mrs E Walsh, Principle Antibiotic Utilisation Pharmacist Miss J Sparrow, Principal Pharmacist, The Walton Centre Miss J Price, Critical Care Pharmacist Sections other than those related to neurology, neurosurgery or neurocritical care are based on those in the Aintree University Hospitals NHS Foundation Trust antimicrobial formulary. Page 5 of 40

6 GENERAL COMMENTS AND ADVICE These guidelines are designed to encourage the rational use of antibiotics and to indicate first choice drugs in many clinical situations, together with an alternative drug or drugs for patients in whom a first choice drug cannot be used. Close and early collaboration between clinicians and medical microbiologists is expected in all difficult, unusual or life threatening infections. The medical microbiologists can provide practical help and advice on appropriate antibiotic therapy in individual patients at any time. Whilst guidelines can provide practical help and advice they are not a substitute for due clinical thought and individual consideration for every patient. Basic Principles Antibiotic treatment should never be delayed in an emergency. Every effort should be made to obtain all necessary bacteriological specimens e.g. CSF, wound swabs, before antibiotic therapy is commenced. If blood cultures are needed: 2 independent sets should be sent. The criteria used in this policy to select empirical antibiotic therapy include: The most probable pathogens Previous antibiotic treatment i) Antibiotic prescribing and course length policy All antibiotics must be prescribed on the dedicated section of The Walton Centre drug kardex (or electronic prescribing and medicines administration EPMA; due to be implemented later in the year). All prescribers must write a stop/ review date and indication on the medicine chart/ antibiotic note on EPMA at the point of prescribing for all antimicrobial agents. The prescribers signature must be legible. Please include bleep numbers and GMC number. The majority of IV antibiotics will require a review rather than a stop date prior to being converted to oral where appropriate. A new review date must be endorsed on the medicine kardex when the prescription is reviewed. Following an IV to PO switch, take into account how many days of IV antibiotics have been given before determining the stop date. Page 6 of 40

7 An example of good practice with review date (most appropriate for initial IV therapy): Drug Flucloxacillin Route IV Dose Date 1/6 2/6 3/6 4/6 5/6 6/6 Indication Cellulitis Pharm RU 1g 0600 as as Start Date 01/06/11 Review Date 03/06/11 Stop date 1g 1200 as as Sensitivities Y/N Prescriber (sign) Micro Approved Y/N GMC No. Formulary Choice Y/N Bleep 1g 1800 as as 1g 2200 as as Dr T Green An example of good practice with stop date (mostly appropriate for oral therapy): Drug Trimethoprim Route PO Dose Date 1/6 2/6 3/6 4/6 5/6 6/6 Indication UTI Pharm RU 200mg 0600 as as as Start Date 01/06/11 Review Date Stop date 04/06/ Sensitivities Y/N Prescriber (sign) Micro Approved Y/N GMC No. Formulary Choice Y/N Bleep 200mg 1800 as as as 2200 Dr T Green Page 7 of 40

8 Weekly collaborative antibiotic ward rounds take place across the Trust which provide advice and assess whether the guidelines are being adhered to. The following points are audited: - Appropriateness of antimicrobials - Dose of antimicrobial - Review or stop dates in place - Documentation of indication on the kardex/ note added to EPMA - Allergy status documented - Prescriber name, bleep & GMC number documented NB If antimicrobials are prescribed on EPMA, a note must be added to state the indication, review date (if stop date not appropriate), plan if necessary etc. ii) Restricted antimicrobials Use of the following antimicrobials is restricted and must be discussed with microbiology/ pharmacy before use: Cefuroxime (except for use in surgical antibiotic prophylaxis) Ceftazidime Ciprofloxacin (except for use in hospital acquired pneumonia in penicillin allergic patients) Co-trimoxazole Co-amoxiclav Ertapenem Linezolid Teicoplanin (except for use in surgical antibiotic prophylaxis) Chloramphenicol (excluding topical preparations and for use in pneumococcal meningitis in penicillin allergic patients) IV antifungals (except for use in Horsley ITU) iii) iv) Hospital and community acquired infections Community-acquired infection is defined as infection developing within 48 hours of being admitted to hospital. Hospital-acquired infection is defined as infection developing later than 48 hours after hospital admission or within 2 weeks of discharge from hospital. Collection of Specimens Every effort should be made to obtain appropriate specimens for microbiological examination before starting treatment. Give the laboratory staff as much helpful information as possible. Please see Buxton labs specimen collection and transport policy (intranet: departments > pathology) Page 8 of 40

9 v) Urgent Treatment In a case where treatment is required urgently before the results of sensitivities are available, an empirical decision should be made regarding the most likely pathogen and its treatment. This should be documented in the patient s notes and on the drug chart. The medical microbiologists are always available to give advice in such cases. vi) Antibiotic Assay monitoring policy Gentamicin/Vancomycin If a patient requires gentamicin or vancomycin the dose will be either initially calculated or if already commenced, checked by a pharmacist. Pharmacists will advise on levels and dosing please ensure ward pharmacist/ on call pharmacists are always informed. This service is available 7 days per week. Out-of-hours the initial dose should be given and then contact on call pharmacist for advice on maintenance dose and blood level monitoring. Pre-dose (trough) levels: take samples immediately before next dose is due. Do not omit the dose whilst awaiting levels, unless advised by a pharmacist. All antibiotic assays (5mls clotted blood, mustard top bottle) should be sent to the Clinical Microbiology Department at University Hospital Aintree. Use the blue microbiology request form. Date and time plus pre or post sample should be clearly stated. ALWAYS RECORD TIME OF DOSE & TIME OF BLOOD SAMPLE ON REQUEST FORM. Page 9 of 40

10 GENTAMICIN Treatment Cautions Administration Monitoring (essential): Gentamicin Dosing: Potential nephrotoxic Infusion in mL of 0.9% For patients given 5mg/kg dose: Once daily doses and ototoxic sodium chloride Measure trough / pre-dose level 5mg/kg (maximum agent or 5% glucose (should be <1mg/L) immediately dose 450mg od) if age<65 years and serum creatinine <150mmol/L in men <120mmol/L in women over 20 minutes. before the second dose. Give the next dose as prescribed. DO NOT withhold dose while awaiting results. Peak levels are not routinely necessary, unless otherwise advised. 3mg/kg for all other patients Renal impairment e.g. Serum creatinine > 200mmol/L or creatinine clearance < 30mL/min. Discuss choice with a consultant medical microbiologist or nephrologist. For patients given 3mg/kg dose: Take 2 timed levels after the first dose: measure first level 1 hour post dose and then a 2 nd level between 7 and 18 hours post-dose. (There must be at least 6 hours between the 2 levels, and times must be recorded.) Record the exact time the sample was taken on the request form. Pharmacist will then calculate an individualised dosage schedule and advise on further monitoring. NB: (i) (ii) (iii) (iv) Avoid using other drugs that enhance nephrotoxicity or ototoxicity e.g. furosemide, bumetanide etc. Avoid courses longer than 5 days unless recommended by a medical microbiologist. Doses should be given at the exact time(s) annotated on the prescription. Do not take levels in patients being treated with ONE single dose only of gentamicin/vancomycin. Page 10 of 40

11 VANCOMYCIN Treatment Cautions Administration Monitoring (essential): Vancomycin Dosing: Pharmacist will advise on maintenance dose Prescribe STAT dose 1g IV and contact oncall/ward pharmacist to discuss further dosing Nephrotoxic agent Prescribe in caution in patients with significant renal impairment (e.g. Serum creatinine > 200mmol/L or creatinine clearance < 30mL/min). In such cases early consideration should be given to discussing antibiotic choice with consultant medical microbiologist/ nephrologist. Give 1g doses over two hours in at least 200mL of 0.9% sodium chloride or 5% glucose. Alert pharmacist Take trough (pre-dose) levels only. Peak measurement no longer recommended. Aim for 10-15mg/L Take 1 st level immediately before the fourth dose. DO NOT withhold dose while awaiting results (unless otherwise advised). vii) Topical Antimicrobials Not recommended unless advised by microbiology or dermatology. viii) Hypersensitivity to Penicillins Penicillin-allergic patients may react to all penicillins. Do not give cephalosporins to patients who have anaphylactic or angioedema reactions to penicillins. In such rare cases, please discuss with a Medical Microbiologist unless otherwise stated in the guideline. Cephalosporins can be given to patients with mild reactions to penicillin (e.g. rash) Penicillin allergy MUST be documented on the in-patient prescription chart or electronically on EPMA, in the case notes and on the orange alert card within 24 hours of admission. Always ensure patient is wearing a red alert wrist band. Always take a complete history and avoid confusion with drug side effects (i.e. vomiting, diarrhoea, thrush). If in doubt, confirm the history by reviewing GP records. Note of caution Tazocin contains piperacillin, a form of penicillin, and should not be given to penicillin allergic patients. Page 11 of 40

12 Co-amoxiclav (Augmentin) contains amoxicillin and should not be given to penicillin allergic patients. ix) Impaired renal and/or hepatic function. All doses suggested are for patients with normal renal and hepatic function. Contact pharmacy for dosing advice in patients with impaired renal or hepatic function. x) Antimicrobial/Antiviral Use in Pregnancy and Breastfeeding These patients should be discussed with pharmacy and microbiology. Contact pharmacy Medicines Information on ext 3208 (during office hours) for advice on the prescribing of any antimicrobial agent in pregnant or breastfeeding patients. xi) Community IV antibiotic therapy service (applies to infections marked *) All patients considered suitable for home IV therapy must be agreed with a medical microbiologist. All patients suitable for home IV therapy will then be referred to the relevant IV community nursing team prior to discharge for assessment, by the consultant medical microbiologist. No patients can be discharged home without having documented acceptance from the community IV team. SEE * THROUGHOUT DOCUMENT FOR CONDITIONS WHERE HOME IV THERAPY MAY BE AN OPTION. Page 12 of 40

13 xii) Sources of specific advice Medical Microbiology Office hours h Saturday am h Extension General office 4900 Dr R Cooke 4916 Dr M Rothburn 4921 Dr P Lal 4907 Dr R Sen 4934 Specialist Registrar 4940 Out-of-hours Contact duty medical microbiologist for medical enquiries or duty biomedical scientist for specimen processing via switchboard Specimen enquiries 4900 Pharmacy Ward Pharmacist Contact in the first instance List on intranet (pharmacy page) Rachel Unsworth Neurology & Neurosurgery Bleep 2134 Pharmacist Jenny Sparrow Lead Neurology & Bleep 2130 / Ext 3987 Neurosurgery Pharmacist Emma Walsh Lead Antimicrobial Pharmacist Bleep 2169 / Ext 3987 Jo Price Horsley/HDU Pharmacist Bleep 5395 Anne Waddington Renal Pharmacist Bleep 2151 / Ext 3987 Sue Fryer/ Medicines Information Ext 3208 Nicola Durnin Pharmacists Out-of-hours On call pharmacist Bleep via switchboard Infection control/ Chris Jessop Bleep 4767 / Ext 5599 Tissue Viability Team Sue Fauld Julia Cottrell Phil Kane Infectious Diseases Unit The Royal Liverpool University Sexually Transmitted Disease Hospital The Royal Liverpool University Hospital Southport & Formby DGH Page 13 of 40

14 Tropical Diseases Tuberculosis All potential cases should be discussed first with the Infectious Diseases Unit (RLUH) OR the Liverpool School of Tropical Medicine, Pembroke Place, Liverpool 3 (Clinical Department) The physicians of the Aintree Chest Unit, University Hospital Aintree should be consulted regarding treatment of tuberculosis, regardless of site of infection Ext 2479 Page 14 of 40

15 HOW TO CONTACT PHARMACY Out of hours (outside the hours 8:30-17:00 Mon-Fri) Bleep on call pharmacist via Aintree switchboard Monday-Friday 08:30-17:00 1. Bleep ward pharmacist (bleep numbers available on the ward) 2. Bleep senior pharmacists at The Walton Centre: Rachel Unsworth: 2134; Jenny Sparrow: Call Aintree pharmacy on ext. 3226/3230 and ask to speak to a pharmacist Page 15 of 40

16 STANDARD PERIOPERATIVE PROPHYLAXIS FOR ALL NEUROSURGICAL PROCEDURES General principles Guidelines Single dosing is generally recommended (i.e. no additional antibiotics post surgery). Prescribe on the once only section of the medicine kardex. Post-operative dosing not recommended. In cases of extended skull base access surgery, check with surgeons for duration of any post-operative antibiotic treatment. 1.5g Cefuroxime at induction (and repeated every 4 hours in prolonged surgery) MRSA positive: Add Teicoplanin IV 800mg single dose Penicillin allergy: Gentamicin IV 120mg single dose & Teicoplanin IV 800mg single dose Procedures involving nasopharynx, oropharynx, or opening of craniofacial air sinuses should also have anaerobic cover: Add metronidazole IV 500mg (single dose, may be repeated) Routine shunt surgery also requires: Intrathecal 5mg gentamicin (single dose) Revisional shunt surgery also requires: Intrathecal 5mg gentamicin and Intrathecal 10mg vancomycin (single doses) (NB Note that Bactiseal systems use rifampicin / clindamycin incorporated into plastic but standard antibiotics as above will also be required) CONDITIONS/ PROCEDURES WHEN PROPHYLAXIS IS NOT REQUIRED: CSF leaks (uncomplicated) Lumber drain insertion for uncomplicated CSF leak Closed skull fractures Closed traumatic CSF fistula Insertion/ changing of urinary catheters Page 16 of 40

17 ANTIBIOTIC TREATMENT REGIMES FOR SPECIFIC NEUROSURGICAL INFECTIONS * = Consider home IV therapy once improving (must discuss with microbiology) Neurosurgical Recommended Course Comments Infection Antibiotic Length 1) Bone Flap Flucloxacillin IV 2g Minimum Infections / qds 6 weeks Osteomyelitis * Penicillin allergy: Clindamycin IV 1.2g qds Step down to oral therapy on medical microbiologists advice. 2) Subdural Empyema * 3) Brain Abscess * Ceftriaxone IV 2g bd plus metronidazole IV 500mg tds or oral metronidazole 400mg tds (await C&S) N.B Bioavailability of metronidazole oral same as IV. If patient taking oral medicines, prescribe oral route. See above (2) Minimum of 3 weeks Minimum of 3 weeks Most bone flaps will be removed. May be left in situ if superficial infection only. Take blood cultures and send tissue biopsy for culture before starting treatment if possible. Surgical evacuation and washout. Removal of bone flap if previous craniotomy. Monitor response by serial imaging & clinical progress. ALWAYS discuss with a clinical microbiologist. Stereotactic aspiration / excision of abscess may need to be repeated. 4) MRSA brain abscess/ subdural empyema/ spinal epidural abscess Vancomycin IV plus rifampicin po 600mg bd 6 weeks See p10 for advice on vancomycin dosing Page 17 of 40

18 Neurosurgical Infection 5) CSF Ventriculitis i) No organisms seen or Grampositive organisms only on Gram film ii) Gram film shows mixed Gram-positive and Gram negative infection iii) Patient systemically unwell Recommended Antibiotic External ventricular drain (EVD) in situ: Send for culture/ sensitivity. Vancomycin intraventricular 10mg od. Vancomycin intraventricular 10mg od plus gentamicin intraventricular 5mg od Add ceftriaxone IV 2g bd Course Length Treat for 5-7 days Ensure CSF sent on 4 th day Comments Need at least 2 CSF specimens to confirm the diagnosis. (Coagulase negative staphylococci likely) No need for CSF drug monitoring. Ensure samples taken from external ventricular drain via port or the ommaya reservoir if fitted (NOT the bag or the end of the draining tube). Get help from a neurosurgeon if required. In most cases the shunt should be removed as soon as possible after the diagnosis of infection is made and external ventricular drainage instituted. Any device removed should have the proximal and distal ends of the shunt submitted for culture (please label as proximal or distal ). No EVD in situ: Ceftriaxone IV 2g bd plus Vancomycin IV (1g stat then contact pharmacy for further advice; see p10) 6) Shunt Infections MRSA Treatment depends on CSF C&S Treat as above (5) Vancomycin IV (see p10) See above (5) Usually require removal of shunt +/- EVD insertion. Shunt may be externalised on occasions Discuss cases with a medical microbiologist/ neurosurgeon. Removal of shunt recommended. Do not replace shunt until CSF cultures negative. Page 18 of 40

19 Neurosurgical Infection 7) * Paraspinal / epidural abscess 8) * Discitis 9) * Spinal metal work infections Recommended Antibiotic Flucloxacillin IV 2g qds Penicillin allergy: Clindamycin IV 1.2g QDS Blind therapy not usually advised until culture results obtained. Flucloxacillin IV 2g qds Step down to: Flucloxacillin po 1g qds C & S essential prior to antibiotic treatment Vancomcin IV 1g single dose then contact pharmacy for further dosing advice. Course Length Response judged by neurology, CRP and imaging. IV antibiotics will be usually needed for a minimum of 3 months 3 months is usual but up to 6 months may be required Extended IV treatment period may be needed Comments May require CT-guided or open decompression (Blind treatment aimed at staphylococcus aureus) Needle biopsy may not show organisms Take blood cultures. ALWAYS discuss with a consultant medical microbiologist. Modern titanium / plastic implants have biofilm characteristics that do not usually necessitate removal as first line treatment. May require wound washout. Page 19 of 40

20 Neurosurgical Infection 10) Brain implant infections - DBS (Deep Brain Stimulators) - Implanted Pulse Generator (IPG) - SCS (Spinal Cord Stimulators) 11) Penetrating craniocerebral injuries/ open skull fractures (non-operated) e.g. gunshot wounds, craniocerebral injuries Recommended Antibiotic Culture and sensitivity essential prior to antibiotic treatment. Flucloxacillin IV 2g qds Penicillin allergy: Clindamycin IV 1.2g qds Ceftriaxone IV 2g bd plus metronidazole po 400mg tds Penicillin allergy (anaphylaxis): Discuss with microbiology Course Length 6 weeks then review Comments ALWAYS discuss with a consultant medical microbiologist first. Implants may need to be removed. 5 days Debridement of devitalised tissue is essential. NB Review the tetanus status of the patient (see appendix 1) Page 20 of 40

21 COMMON NEUROSURGICAL MANAGEMENT ISSUES Neurosurgical issue a) Pin site/ Halo infections Comments Wash with soap and water (not chlorhexidine) May not require antibiotics. Discuss with a medical microbiologist before treating with antibiotics. Liaise with infection control nurses b) Post-operative CSF leaks e.g. skull base CSF leak by itself does not mean infection and does not require treatment. NB Blind antibiotic prescribing encourages resistance Assess for meningism, infective signs, etc. Wound swab +/- CSF sample is vital. Wound washout may prove necessary. c) CSF sampling d) Extended antibiotic treatment Routine sample at time of EVD / Lumbar drain insertion. If not infected, no additional samples required unless clinical suspicion of infection, or 48hr prior to shunt conversion. If infected, sample every 4 days until infection cleared, and 48hr prior to shunt conversion. When IV antibiotics likely to continue for >5 days try to anticipate this and request insertion of long line/ midline. Liaise with community IV team & microbiology to ensure seamless antibiotic dosing. Notify GP practice for follow up, CRP, WCC monitoring etc. Page 21 of 40

22 MENINGITIS Non-neurosurgical meningitis is a notifiable disease and should be reported within 24 hours of admission to the Health Protection Unit (HPU) by the attending clinician. HPU telephone number within working hours: 0151 numbers have changed: (Merseyside), (Cheshire); outside working hours contact the Royal Liverpool University Hospital switchboard on and ask for the on call public health. Take two independent blood cultures, EDTA blood sample for meningococcal/ pneumococcal PCR, bacterial throat swab for meningococcal carriage and acute serum. Always discuss cases early with a medical microbiologist. N.B The full antibiotic course should be given by the parenteral route. CLINICAL RECOMMENDED COURSE COMMENTS CONDITION ANTIOBIOTICS LENGTH Pneumococcal Meningitis 14 days Meningococcal meningitis or septicaemia Listeria meningitis Ceftriaxone IV 2g bd Anaphylaxis or angioedema to penicillin: Chloramphenicol IV 25mg/kg qds plus Vancomycin IV, 1g stat then contact pharmacy for further dosing advice (see p10). Treatment as above Amoxicillin IV 2g 4-6 hourly (plus IV gentamicin (see p8-9) for at least 7 days if confirmed) Penicillin allergy: Co-trimoxazole IV 120mg/kg/day in 2-4 divided doses 7 days 21 days Medical Microbiologist will advise Chloramphenicol monitoring essential - contact microbiology for advice. Consider in any patients >55 years with suspected bacterial meningitis. Co-trimoxazole: monitor levels. Microbiology to advise (caution in renal impairment). Page 22 of 40

23 POSTOPERATIVE NEUROSURGICAL MENINGITIS Usually caused by Staphylococcus aureus and Gram-negative bacilli. Treat with parenteral antibiotics for 2-3 weeks. Always discuss with a medical microbiologist. Clinical setting/pathogen Intravenous Regime First-line empirical therapy Ceftriaxone IV 2g bd If either Patient has recently received a broadspectrum antibiotic Meropenem IV 2g tds or Suspected or confirmed ESBL-producing Enterobacteriaceae or Acinetobacter sp. Methicillin-susceptible S. aureus Flucloxacillin IV 2g six times daily Penicillin allergic: Methicillin-resistant S. aureus (suspect if positive on screening). Vancomycin IV 1g single dose & dose further as advised by pharmacy (see p10) plus Rifampicin 600 mg bd (oral / IV) Vancomycin IV 1g single dose & dose further as advised by pharmacy (see p10) plus Rifampicin 600 mg bd (oral / IV) Page 23 of 40

24 ENCEPHALITIS Please see for guidelines on investigation CLINICAL CONDITION Encephalitis (Parenchymal Brain Infection) Start blind therapy initially and seek micro advice immediately Lyme disease PROBABLE PATHOGEN Viral : - Herpes simplex - Varicella Zoster virus Bacterial : - Listeria monocytogenes - Treponema pallidum (Syphilis) - Mycobacterium tuberculosis Fungal: - Cryptococcus neoformans (Cryptococcosis) Borrelia burgdorferi RECOMMENDED ANTIBIOTICS Blind antimicrobial therapy: Aciclovir 10mg/kg IV 8 hourly plus Ceftriaxone 2g IV bd (if anaphylaxis or angioedema to penicillin, use chloramphenicol IV 25mg/kg QDS) If over 55 years add in amoxicillin IV 2g QDS to treatment. (if penicillin allergic, co-trimoxazole IV 120mg/kg/day in 2-4 divided doses) Discuss with a medical microbiologist. Ceftriaxone 2g IV od Penicillin allergic: discuss with a medical microbiologist. Please see for guidelines on investigation. COURSE LENGTH 3 weeks (Herpes simplex) 3 weeks Microbiological investigation should include blood cultures, CSF examinations (for routine bacterial culture & microscopy) & EDTA clotted blood sample. With infectious causes, there is usually a lymphocyte reaction in the CSF. A repeat CSF after 24 to 72 hours is a useful index of response to treatment. NB Pnemococcal and meningococcal infection may occasionally present as meningoencephalitis. Listeriosis is a rare infection usually seen in immunocompromised patients. A single serum sample (clotted blood) can be sent for Syphilis and Lyme disease serology. Acute and convalescent ( 21 days into illness) serum will be needed in order to determine a significant rise in antibody titres. Page 24 of 40

25 PNEUMONIA Note: In pneumonia, 2 independent blood cultures should be taken as well as sputum samples in all patients with CURB-65 > 3 CLINICAL CONDITION Non-Severe Communityacquired pneumonia (CURB-65 score = 0-2) PROBABLE PATHOGEN Streptococcus pneumoniae Mycoplasma pneumoniae (if <40 years) RECOMMENDED ANTIBIOTICS CURB-65 = 0-1 Amoxicillin po 500mg tds If penicillin allergic use erythromycin po 500mg qds. 2 nd line: doxycycline 100mg bd CURB-65 = 2 or if prior use of antibiotics: Amoxicillin po 500mg tds plus erythromycin po 500mg qds 2 nd line: doxycycline 100mg bd COURSE COMMENTS LENGTH 5 days CURB-65 score Calculate CURB-65 score for patients with community acquired pneumonia. Score 1 point each for the following: - Confusion - Urea >7mmol/L - Resp rate >30/min - BP Low (Diastolic BP<60mmHg or Systolic BP <90mmHg) - Age 65years Page 25 of 40

26 CLINICAL CONDITION Severe Communityacquired pneumonia Hospital Acquired Pneumonia (Non-ITU) PROBABLE PATHOGEN As above plus Staphylococcus aureus, Legionella sp Streptococcus pneumoniae, Staphylococcus aureus and Coliforms Pseudomonas usually seen in ITU setting RECOMMENDED ANTIBIOTICS CURB-65 3 Benzylpenicillin IV 1.2g qds plus clarithromycin IV 500mg bd. Step down to amoxicillin po 500mg tds and erythromycin 500mg qds after 24 hours if stable and improving. Penicillin Allergy: Vancomycin IV 1g stat then contact pharmacy for further dosing advice (see p10). Plus Clarithromycin IV 500mg bd Tazocin IV 4.5g tds. Oral step down : Cefaclor 500mg tds Penicillin allergic: Ciprofloxacin po 750mg bd (IV 400mg BD if NBM) & Clarithromycin IV 500mg bd Oral step down is Erythromycin 500mg qds & continue oral ciprofloxacin 750mg bd COURSE COMMENTS LENGTH 5 days Severe pneumonia defined as CURB-65 score of 3-5 Review after 48 hours to assess if suitable for oral therapy. Total course length 5 days Total treatment course should be for 5 days initially, then reviewed. If not responsive discuss with consultant medical microbiologist. Page 26 of 40

27 CLINICAL CONDITION Aspiration pneumonia (Non ITU) MRSA pneumonia PROBABLE PATHOGEN As above plus anaerobes MRSA RECOMMENDED ANTIBIOTICS Community acquired: Amoxicillin IV 500mg tds & Metronidazole IV 500mg tds Penicillin allergy: Clarithromycin IV 500mg & Metronidazole IV 500mg tds Hospital acquired: Tazocin IV 4.5g tds Penicillin allergic: Ciprofloxacin IV 400mg bd & Clarithromycin IV 500mg bd & Metronidazole IV 500mg tds. Vancomycin IV 1g stat then contact pharmacy for further dosing advice. (see p10) COURSE LENGTH Total course length 5 days COMMENTS Antibiotics not indicated in chemical pneumonitis days Based on clinical response GASTRO-INTESTINAL INFECTIONS CLINICAL CONDITION Infective diarrhoea Antibiotic associated colitis (Clostridium Difficile Infection (CDI)) PROBABLE PATHOGEN Viral (e.g Norovirus), campylobacter, salmonella Clostridium difficile RECOMMENDED ANTIBIOTICS None if systemically well. Otherwise take blood cultures and seek microbiology advice. Refer to Trust Guidelines on intranet for Clostridium Difficile management (policies > infection control policies) COURSE LENGTH 10 days COMMENTS Approximately 20% ciprofloxacin resistance for campylobacter. Page 27 of 40

28 SEPTICAEMIA Take TWO independent blood culture sets (See guidelines on taking blood cultures on intranet: Policies >infection control policies) Aim to investigate and start appropriate antimicrobial therapy within ONE hour This section is for those patients NOT going to ICU: CLINICAL CONDITION Community acquired septicaemia (pts admitted <48 hours) Hospital acquired septicaemia (pts admitted >48 hours or readmitted within 2 weeks of discharge) PROBABLE PATHOGEN Coliforms e.g. Klebsiella sp Proteus sp E.coli sp Meningococcus Pseudomonas sp Enterococci, Staphylococcus aureus, including MRSA. RECOMMENDED ANTIBIOTICS Tazocin IV 4.5g tds Pencillin allergy: Vancomycin IV 1g stat then contact pharmacy for further advice Plus IV gentamicin Ceftriaxone IV 2g bd Tazocin IV 4.5g tds plus Stat dose only Gentamicin IV. If MRSA carrier: consider additional cover with IV vancomycin Penicillin allergy: Vancomycin 1g IV plus Gentamicin IV COMMENTS Discussion with medical microbiologist is essential Take blood cultures. Always discuss gentamicin and vancomycin doses with a pharmacist (see p8-10) See Meningitis guidelines 2 independent blood cultures must be sent before starting antimicrobials. Careful assessment for source of sepsis is required. If cause is infected central line remove line. Review after 48 hours when blood culture results available. Vancomycin IV 1g stat dose only and discuss further dosing with pharmacist (see p8-10 for advice on gentamicin and vancomycin dosing). Page 28 of 40

29 CLINICAL CONDITION Neutropenic sepsis (neutrophil count <1.0) and immunocompromised patients. MRSA Sepsis due to Methicillin resistant Staphylococcus aureus Central IV catheter sepsis PROBABLE RECOMMENDED PATHOGEN ANTIBIOTICS Pseudomonas Gentamicin IV stat aeruginosa, dose only Coliforms, plus tazocin IV Streptococci, 4.5g tds Staph aureus. Penicillin allergy: Meropenem 1g tds alone. MRSA Vancomycin IV (1g stat and discuss further dosing with pharmacist) Staph aureus (including MRSA), Coagulase negative staphylococci variety of Gram negative Treat for 14 days Vancomycin IV (1g stat and discuss further dosing with pharmacist; see p10) plus Gentamicin IV (see p8-9) COMMENTS Discuss course length with microbiologist Contact pharmacy for gentamicin dosing advice (see p8-9) Discuss with Microbiologist and pharmacist as soon as possible. Contact pharmacy for vancomycin dosing (see p10). Paired central and peripheral blood cultures essential and clearly marked on microbiology request form. ITU review and central line removal need to be considered. Discuss with medical microbiologist and pharmacist as soon as possible. Page 29 of 40

30 URINARY TRACT INFECTIONS General Comments 1. For advice on UTI in patients over 65 years see algorithm page These recommendations are for initial therapy. Culture and sensitivity results should be used to change to more appropriate agents when the information becomes available. 3. The use of newer very broad-spectrum antibiotics is not encouraged. Their misuse will lead to increasing levels of drug resistance & c. difficile infection. Their value will therefore be reduced when they are most needed. 4. Gentamicin must be monitored with blood level assays - see page For advice on when to take blood cultures see Trust intranet: Policies >Infection control policies > Taking blood cultures. 6. Always label urine samples i.e. MSU or CSU CLINICAL CONDITION Simple uncomplicated acute UTI in women only. Complicated / Upper Renal Tract Infection e.g. all men, acute pyelonephritis and recurrent UTI RECOMMENDED ANTIBIOTICS Trimethoprim po 200mg bd Tazocin IV 4.5g tds or Cefalexin po 500mg tds. Penicillin allergy: Gentamicin IV od COURSE COMMENTS LENGTH 3 days Send urine for culture and adjust therapy accordingly. Avoid trimethoprim in patients with renal impairment days Follow up urine culture to identify relapse of infection. For MRSA and ESBL UTI, always discuss with Microbiology. Check renal function. See p8-9 for gentamicin dosing advice. Page 30 of 40

31 CLINICAL CONDITION Bladder catheter in-situ or Intermittent selfcatheterisation (ISC) e.g. Neurogenic bladder, MS patients Frequent UTIs RECOMMENDED ANTIBIOTICS Treat only if symptomatic. DO NOT TREAT based on positive urine dipsick alone (bacterial bladder colonisation is common and does not require treatment) Treat according to cultures and sensitivities Possible need for long term antibiotic prophylaxis COURSE COMMENTS LENGTH 5 days 1. Ensure high fluid intake 2. There is a high incidence of bacteruria with long term catheters. Antibiotics do not eliminate these, but lead to growth of resistant organisms. 3. Bladder washouts are not recommended. 4. Urine dipstick analysis is invariably positive and therefore unhelpful. 5. Urine culture is inappropriate unless accompanied by 2 independent blood cultures. Must always be discussed with microbiology Low dose nitrofurantoin or trimethoprim are the most suitable agents. Choice will depend on sensitivity pattern. Page 31 of 40

32 Suspected Urinary Sepsis Acute Symptoms Catheterised patient As cause of Acute Confusional State No Withhold antibiotics Frequency, Dysuria Incontinence Yes No Is there evidence of systemic infection, temp >38 o C or WBC Blood Cultures x2 + MSU Yes Antibiotic treatment as per hospital guidelines Ward Test Urine Send MSU if dipstick positive for blood, WBC or nitrate. Blood cultures X2 if one of the following: loin pain or rigor, features of systemic infection, temp>38 o C, WBC No Withhold Antibiotics CSU and blood culture x2 if evidence of systemic infection: temp >38 o C, WBC or loin pain or rigors No Withhold Antibiotics Yes No Withhold Antibiotics Is there evidence of systemic infection: temp >38 o C, WBC. If so, MSU if possible and blood culture x2 Antibiotic treatment as per hospital guidelines Yes Remember: Asymptomatic bacteriuria in the elderly is common and does not need treatment A negative dipstick for leukocytes blood and nitrate can exclude UTI In catheterised patients, urine dipstick and culture are invariably positive Abnormal white cell count (WBC) is considered to be >12 or <4 (part of SIRS criteria) Page 32 of 40

33 SKIN INFECTIONS CLINICAL CONDITION Intravenous peripheral cannula site infection Central IV catheter site infection Cellulitis MRSA soft tissue infection PROBABLE PATHOGEN S. aureus including MRSA S. aureus including MRSA S. pyogenes and other beta haemolytic Streptococci. S. aureus. MRSA RECOMMENDED ANTIBIOTICS Oral/ IV antibiotics may be indicated need to discuss with consultant microbiologist/ infection control nurses IV flucloxacillin 1g 6 hourly or Vancomycin IV if known MRSA carrier & systemically unwell. (For penicillin allergy, see cellulitis guideline) Flucloxacillin IV 1g qds plus benzylpenicillin IV 1.2g qds Oral step down to amoxicillin 500mg tds plus flucloxacillin 500mg qds Penicillin allergy: Clarithromycin IV 500mg bd Oral step-down to Erythromycin 500mg qds Vancomycin IV (see p10 for dosing advice) COURSE LENGTH Always seek advice from microbiology if known MRSA carrier IV for 48 hours then review Total course length: 5-10 days COMMENTS Swab site and take blood cultures. Remove cannula. Inform microbiology & infection control. See p10 for advice on vancomycin dosing. Contact infection control team Mark edge of redness. Bilateral cellulitis is very unusual, reconsider diagnosis days Discuss with medical microbiologist Page 33 of 40

34 TUBERCULOSIS (Including non-pulmonary tuberculosis) BNF: ** The Microbiology Department provides a rapid TB PCR service for all newly diagnosed patients with AFB smear-positive sputum. Always discuss suspected cases with the Physicians in the Department of Thoracic Medicine, University Hospoital Aintree. For all forms of TB, start with four first line drugs (Rifampicin, Isoniazid, Pyrazinamide and Ethambutol) for initial 8 weeks. Check baseline U&Es and LFTs. Weigh patient (dose patient according to weight). First line: Rifater (rifampicin, isoniazid and pyrazinamide). Weight <40kg Three tablets od 40-49kg Four tablets od 50-64kg Five tablets od >65kg Six tablets od Ethambutol: 15mg/kg od (to the nearest 100mg). When possible use fixed dose combinations (Rifater or Rifinah ) as an aid to compliance. Isoniazid Rifampicin Pyrazinamide Ethambutol Can cause peripheral neuropathy. Consider Pyridoxine 10mg po od as prophylaxis in susceptible patients e.g. elderly, malnourished. Induces liver enzymes causing interactions with other drugs Often causes nausea and skin rashes. Test visual acuity Unconscious patient: Use naso-gastric tube if possible, otherwise seek advice from Respiratory team or Microbiology (ask pharmacist for advice on formulations) If patient NBM: Rifampicin IV od, isoniazid IV od, streptomycin IM 15mg/ kg/ day. TB Meningitis Treat as above plus add in steroids see table below Treatment Course length Comments Dexamethasone 12mg total daily dose 3 weeks Then reduce dose gradually over following 3-4 weeks. Rare condition. Always seek advice from a Consultant Medical Microbiologist if the diagnosis is considered likely. Refer to BTS guidelines Page 34 of 40

35 TREATMENT AND ERADICATION OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) If systemic MRSA infection is suspected or proven please discuss with consultant microbiologist and refer to: guidelines on the treatment of MRSA infections on the intranet (Policies > infection control policies > MRSA control and prevention) Eradication of MRSA by the use of topical anti-staphylococcal treatment: Use Octenisan for body bathing, showering or bed bathing. Use the skin cleanser as a liquid soap and shampoo. Wash from head to toe, using a fresh disposable cloth, once daily. Wash vigorously, paying particular attention to the following areas: Hair Around the nostrils Under the arms Between the legs Octenisan should be in contact with the skin for about 3 minutes. Rinse from head to toe and dry the skin well. Follow this regimen for at least 5 days In addition, for eradication from the nose apply Mupirocin (Bactroban nasal ) ointment to the anterior nostrils 3 times a day for 5 days. This has to be prescribed by a doctor on the advice of the infection control team. Page 35 of 40

36 HORSLEY ITU/ HDU ANTIMICROBIAL POLICY ANTIBIOTIC REGIMES FOR SPECIFIC CLINICAL CONDITIONS IN THE INTENSIVE CARE UNIT (ICU) 1. Lower respiratory tract infections in ICU patients N.B. Treatment should not be started on chest X-ray changes alone but rather on clinical parameters. CPIS Points ( Clinical Pulmonary Infection Score) Please circle Score Tracheal Secretions Few Abundant Abundant & Purulent Chest X-Ray infiltrates No infiltrates Diffused Localised Progression of Chest X-Ray infiltrates over 72 hours Temperature None Progression (if heart failure & ARDS excluded) >39 or <36 >36.5 and <38.4 >38.5 and <38.9 Leukocytes count >4000 and <4000 or <4000 or > 11,000 + < >11,000 band forms > 500 PaO 2 /FIO 2,kPa >32 or ARDS <32 and no evidence of ARDS Microbiology No growth/or scanty or + growth + + Growth Growth Score of 6 or more suggests Ventilator Associated Total score Pneumonia Page 36 of 40

37 CLINICAL CONDITION Early onset hospital acquired pneumonia (HAP) <5 days ventilation HAP or Ventilator associated Pneumonia >5 days ventilation Hospital-acquired aspiration pneumonia (confirmed soiling of bronchial tree plus infection) N.B. Bronchoscopy can help confirm aspiration Subsequent pneumonia after previous course of tazocin RECOMMENDED ANTIBIOTICS Tazocin IV 4.5g TDS Tazocin IV 4.5g TDS Plus Gentamicin 5mg/kg IV od Tazocin 4.5g IV TDS Note aspiration causes chemical pneumonitis antibiotics not always indicated Meropenem IV 1g tds PENICILLIN ALLERGIC Non- Anaphylaxis to penicillin : Ceftazidime IV 2g tds plus metronidazole IV 500mg tds Anaphylaxis with penicillin : Meropenem IV 1g tds COURSE LENGTH 5 days 2. Intra-abdominal infections (peritonitis) on ICU Contact a medical microbiologist for specific advice 3. Peripheral cannula infections on ICU Peripheral cannulae sites should be reviewed daily and unnecessary ones removed Remove any infected line and submit for culture, take blood cultures If localised infection flucloxacillin IV 1g qds / flucloxacillin PO 1g qds for 5 days If systemically unwell: vancomycin IV 1g stat (then contact pharmacy for further dosing advice; see p10) For penicillin allergy use clarithromycin IV 500mg bd / erythromycin PO 500mg qds for five days Page 37 of 40

38 4. Central line infections on ICU Diagnosed by peripheral and central blood cultures growing the same organism or in the presence of exit site infection. N.B. where lines are removed, submit tip for culture if blood cultures have also been taken. PROBABLE PATHOGEN RECOMMENDED ANTIBIOTICS Coagulase negative Staphylococci Usually no antibiotics needed Gram negative bacilli Often no antibiotics needed treat individually Staphylococcus aureus: Always review at 48 hours after blood culture results. Always treat as may disseminate. Methicillin-resistant (MRSA) Vancomycin IV 1g stat (then contact pharmacy for further dosing advice; see p10) for 14 days Methicillin-sensitive Flucloxacillin IV 2g qds for 14 days (for penicillin allergy, follow MRSA guideline above) Candida sp. Remove line and treat for 14 days (See below section on disseminated candidiasis) 5. Management of Candidiasis in ICU (a) Therapy based on positive blood cultures or surveillance cultures Empirically use caspofungin 70mg first dose then: o 70mg daily if body weight >80kg o 50mg IV daily if body weight <80kg o 35mg daily in liver impairment (Child Pugh class C score 10-15) Switch to oral fluconazole 800mg loading dose and then 400mg daily if candida albicans isolated. Usually treat for 14 days. Consider central line replacement at the time antifungal therapy is started. Neither fluconazole or caspofungin are suitable for CNS infections as they do not penetrate the CNS. Liposomal Amphotericin B (AmBisome 5mg/kg/day) is usually the preferred agent, but always discuss with a consultant microbiologist. (b) Pre emptive antifungal therapy Based on patients colonisation index (ratio of number of body sites colonised versus total number tested) and clinical scenario. Choice of caspofungin/ fluconazole will depend on strains of candida isolated. Discuss with medical microbiologist. 6. Postoperative Meningitis on ICU Usually caused by Staphylococcus aureus and gram negative bacilli. Treat with parenteral antibiotics for 2-3 weeks. Always discuss with a microbiologist and neurosurgeon. See page 24 for treatment guidelines. Page 38 of 40

39 7. Septicaemia CONDITION Septicaemia (unknown source) PROBABLE PATHOGEN If suspected MRSA carrier RECOMMENDED ANTIBIOTICS Tazocin IV 4.5g tds plus Gentamicin (5mg/kg IV OD) If penicillin allergy substitute vancomycin (see p10) for Tazocin and add metronidazole 500mg IV tds. Add in Vancomycin IV 1g stat and dose further as advised by pharmacist (see p10) COURSE COMMENTS LENGTH 5 days Defined as 2 or more of the following SIRS criteria: Temperature > 38 o C or <36 o C Heart rate > 90 bpm Respiratory rate >20 breaths/min. White cell count > 12 x 10 9 /L or <4 x 10 9 /L PaCO 2 < 4.2kPa 8. Management of bladder associated infection on ICU Bacteriuria in the presence of a urinary catheter is not an indication for antibiotics unless systemic infection is suspected or prior to genito-urinary surgery. Do not send a CSU unless also sending independent blood cultures. Page 39 of 40

40 APPENDIX 1 If the wound or burn fulfils the above criteria and is considered to be high risk (heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue) then tetanus immunoglobulin should be given for immediate protection irrespective of the tetanus immunisation history. Otherwise follow the guidance listed below. Specific Anti-Tetanus Prophylaxis Immunisation Clean Wound Tetanus-Prone Wound Status Vaccine Vaccine Human Tetanus Immunoglobulin Fully immunised, ie has received a total five doses of vaccine at appropriate intervals 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 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 Note: Revaxis at a dose of 0.5mL intra-muscular is the formulation used at Aintree. This is a combined Diptheria / Tetanus / Poliomyelitis vaccine available in the AED department. Page 40 of 40