Women s Antimicrobial Guidelines Summary 1. Introduction and Who Guideline applies to This guideline has been developed to deliver safe and appropriate empirical use of antibiotics for patients at University Hospitals of Leicester NHS Trust. The guideline applies to adult inpatient and discharge prescriptions and should be used in conjunction with the Antimicrobial Prescribing Policy; it can also serve as a guide to prescribing in the outpatient setting. The recommendations within this guideline provide targeted empirical regimens covering likely pathogenic organisms for defined infections and aim to promote the evidence based use of antibiotics, minimise the effect of antibiotics on the patient's normal bacterial flora and adverse effects. General rules: - Take appropriate specimens for microscopy, culture and sensitivity testing prior to starting antibiotics. The choice of antibiotic should be reviewed with the culture and antimicrobial sensitivity results - Intravenous (IV) therapy should be reserved for those patients who are seriously ill with moderate to severe infections or are unable to take medications enterally. - Review IV treatment within 2 days with a view to switching to oral therapy as soon as clinically appropriate. The antibiotic doses recommended in this guidance are intended for adult patients with normal renal and liver function. Refer a Pharmacist for further advice in these patients, advice for dose recommendations in renal impairment can be found on the Antimicrobial Website. Women s Antimicrobial Guidelines Summary Page 1 of 7
2. Guideline Standards and Procedures 1. GYNAECOLOGY 1.1. Gynaecology (not pregnant) - Empiric Treatment Guidelines Recommended antibiotics total duration of antibiotics Indication (IV+PO) is 5 days unless otherwise stated Pelvic Inflammatory Disease Refer to UHL guideline PO 400mg BD for 7 days OR 0.75% vaginal gel 5g applicatorful at night for 5 days Bacterial Vaginosis Alternative: Clindamycin 2% cream 5g applicatorful at night for 7 days Doxycycline PO 100mg BD for 7 days Alternative if intolerant to doxycycline: azithromycin PO 1g stat Refer to GUM clinic via email (dailyresults.stpeters@nhs.net) with the Chlamydia trachomatis Genital Tract patient details below for follow up, contact tracing and blood borne virus Infection testing. Post-op infection Gonococcal Infection Wound infection Suspected intraabdominal source (no peritoneal soiling) Suspected intra - abdominal source with peritoneal soiling UTI Sepsis All patients with suspected sepsis or EWS of 3 or more should be assessed using the Adult Sepsis Screening and Immediate Action Tool Sepsis unknown origin where Red Flag Sepsis NOT identified - see Antimicrobial Website Labial/bartholin abscesses Patient name, hospital number/nhs number, DOB and telephone number will be needed in order for GUM to contact the patient. Do not treat. Treatment will be provided at the GUM clinic. Refer to GUM clinic via email (dailyresults.stpeters@nhs.net) with the patient details above for treatment, follow up, contact tracing and blood borne virus testing Flucloxacillin PO 500mg QDS If penicillin allergy: Doxycycline 200mg OD Co-amoxiclav PO 625mg TDS If NBM: Co-amoxiclav TDS until enteral route available Add in IV 7mg/kg* OD (contact pharmacist prior to prescribing, max 640mg) for severe infections If penicillin allergy: PO 400mg TDS + Ciprofloxacin PO 500mg BD If NBM: TDS + IV Ciprofloxacin 400mg BD converting to enteral route when available Co-amoxiclav TDS +/- IV 7mg/kg* OD (contact pharmacist prior to prescribing, max 640mg) for severe infections Switch to Co-amoxiclav PO 625mg TDS when enteral route available If penicillin allergy: TDS + IV Ciprofloxacin 400mg BD converting to enteral route when available ( PO 400mg TDS + Ciprofloxacin PO 500mg BD) Refer to full Trust UTI guideline on Antimicrobial Website If Red Flag Sepsis identified: give a STAT dose of Meropenem IV 1g from Sepsis Box. Do not continue meropenem beyond doses available in Sepsis Box without microbiology advice and verification code. If Red Flag Sepsis NOT identified and patient is well or improving: prescribe antibiotics as per guideline for identified source of infection. Co-amoxiclav TDS If penicillin allergy: PO 400mg TDS and Ciprofloxacin PO 500mg BD. If NBM: TDS + IV Ciprofloxacin 400mg BD converting to enteral route when available. Incision and drainage should be considered. Uncomplicated abscesses that have been drained may not require antibiotics. Flucloxacillin PO 500mg QDS If penicillin allergy: Doxycycline PO 200mg OD *NB: refer to Antimicrobial Website for dosing, frequency and monitoring requirements. Women s Antimicrobial Guidelines Summary Page 2 of 7
1.2. Gynaecology Surgical Prophylaxis Review requirement for additional prophylaxis if antibiotic doses have been administrated in the previous 24 hours. Surgical procedure Gynaecology major Prophylaxis regimen (single dose and given at induction) Standard Regimen Co-amoxiclav If peritoneal soiling give a further 2 doses post-op Known or Previously known MRSA positive patients Co-amoxiclav If peritoneal soiling give a further 2 doses of Coamoxiclav post-op Prophylaxis regimen for penicillin allergic patients ( single dose and given at induction) Standard Known or Previously known regimen MRSA positive patients Surgical Termination of Pregnancy All patients undergoing abortion should be screened for Chlamydia trachomatis, Gonorrhoea and Syphilis. Hepatitis B risk factors are assessed and HIV screening is offered. A risk assessment for other STIs should be done and the patient screened if deemed appropriate. Any positive STI screens should be referred to GUM for follow up and partner notification. Prophylaxis is only needed for surgical abortions (given 2 hours before procedure): 1) If result of STI screen is unavailable/c. trachomatis positive: PO Azithromycin 1g + PR metronidazole 1g* 2) If negative for C. trachomatis: PR metronidazole 1g* only *Oral metronidazole 800mg can be used instead of the PR route. Doses recommended for adult patients with normal renal and liver function. For further information refer to Antimicrobial website. Antibiotic prophylaxis is NOT routinely recommended in the following procedures: 1. Evacuation of incomplete miscarriage 2. Intrauterine contraceptive (IUCD) insertion 3. Medical termination of pregnancy Women s Antimicrobial Guidelines Summary Page 3 of 7
2. OBSTETRICS 2.1. Obstetric - EmpiricTreatment Guidelines Indication UTI in pregnancy Duration of antibiotics = 7 days Pyelonephritis in pregnancy Sepsis Recommended antibiotics total duration of antibiotics (IV+PO) is 5 days unless otherwise stated Perinatally: consider using IV rather than oral antibiotics due to gastric stasis 1st Trimester 2nd Trimester 3rd Trimester Nitrofurantoin PO 100mg MR BD or Cefalexin PO 500mg TDS Nitrofurantoin PO 100mg MR BD or Trimethoprim PO 200mg BD Trimethoprim PO 200mg BD or Cefalexin PO 500mg TDS Use urine culture and sensitivity results, when available to review antibiotic choice. NB: Nitrofurantoin should not be used beyond 32 weeks Cefuroxime IV 1.5g TDS for 24 hours (or until enteral route is available if NBM) Switch to Cefalexin PO 500mg TDS when enteral route available and patient clinically improving. When urine culture and sensitivity results available review antibiotic choice. If unresponsive to Cefalexin or penicillin allergy, discuss with microbiology. Complete a total of 14 days effective treatment All patients with suspected sepsis or MEOWS of 3 or more should be assessed using the Adult Sepsis Screening and Immediate Action Tool Intra-partum pyrexia (Temperature 38 o C or 37.8-37.9 o C twice 2 hours apart) where Red Flag Sepsis NOT identified Antenatal sepsis of unknown origin where Red Flag Sepsis NOT identified Chorioamnionitis Endometritis postsurgical evacuation or evidence of infection following manual removal Premature rupture of membranes Prophylaxis for third & fourth degree tears If Red Flag Sepsis identified: give a STAT dose of Meropenem IV 1g from Sepsis Box. Do not continue meropenem beyond doses available in Sepsis Box without microbiology advice and verification code. If Red Flag Sepsis NOT identified and patient is well or improving: prescribe antibiotics as per guideline for identified source of infection. For treatment, refer to the Pyrexia and Sepsis in Labour Guideline. http://insitetogether.xuhltr.nhs.uk/pag/pagdocuments/pyrexia%20in%20labour%20uhl%20obstetric%20guideline.pdf Cefuroxime IV 1.5g TDS + TDS Switch to Cefalexin PO 500mg TDS + PO 400mg TDS when enteral route available and patient has sustained clinical improvement for at least 24 hours If cephalosporin/penicillin allergy: IV Clindamycin 900mg TDS + PO Ciprofloxacin 500mg BD Switch to Clindamycin PO 300mg QDS + Ciprofloxacin PO 500mg BD when enteral route available and patient clinically improving. Co-amoxiclav PO 625mg TDS (If NBM: Co-amoxiclav TDS switching to oral when route available) If penicillin allergy: Clindamycin PO 300mg QDS + Ciprofloxacin PO 500mg BD (If NBM: Ciprofloxacin IV 400mg BD and Clindamycin IV 900mg TDS) For antibiotic prophylaxis (STAT dose) following removal of retained placenta please refer to page 7 Erythromycin PO 250mg QDS for 10 days (or until baby is born, whichever is sooner). If allergic or intolerant to Erythromycin: Phenoxymethylpenicillin PO 250mg QDS for 10 days (or until baby is born, whichever is sooner) Co-amoxiclav TDS If penicillin allergy: Clindamycin IV 900mg TDS (Oral route can be used after first dose if patient able to tolerate) Women s Antimicrobial Guidelines Summary Page 4 of 7
Indication Infected abdominal wound post section Infected perineal wound Mastitis Lower Respiratory Tract Infection (with purulent sputum) Community Acquired Pneumonia (antenatal) For post-natal patients treat as per Pneumonia Trust Guidelines, substituting clarithromycin for doxycycline if breastfeeding Recommended antibiotics total duration of antibiotics (IV+PO) is 5 days unless otherwise stated Flucloxacillin PO 1g QDS If penicillin allergy: Clindamycin PO 300mg QDS Flucloxacillin PO 1g QDS + PO 400mg TDS If penicillin allergy: Clindamycin PO 300mg QDS Review in 48 hours. If no improvement liaise with microbiology. Flucloxacillin PO 500mg QDS for 7 days If penicillin allergy: Clarithromycin PO 500mg BD for 7 days Amoxicillin PO 500mg TDS If penicillin allergy, discuss with microbiology CURB65 1: Amoxicillin PO 500mg TDS CURB65 = 2: Amoxicillin PO 1g TDS and Clarithromycin PO 500mg BD CURB65 3: Amoxicillin TDS and Clarithromycin PO 500mg BD Refer to Trust Pneumonia guideline or Antimicrobial Website for definition of CURB65. If penicillin allergy or unresponsive to empiric antibiotics, discuss with microbiology. Women s Antimicrobial Guidelines Summary Page 5 of 7
Obstetric SURGICAL PROPHYLAXIS Surgical procedure Caesarean section Removal of retained placenta Prophylaxis regimen (single dose and given at induction) Standard regimen Co-amoxiclav Co-Amoxiclav Known or Previously known MRSA positive patients Co-amoxiclav Co-amoxiclav Prophylaxis regimen for penicillin allergic patients (single dose and given at induction) Standard Known or Previously known regimen MRSA positive patients Prophylaxis to be administered until balloon has been removed Massive haemorrhage or Bakri balloon in situ Co-Amoxiclav Co-amoxiclav Ensure antibiotics given are recorded on drug chart in addition to anaesthetic chart. Doses recommended for adult patients with normal renal and liver function. For further information refer to Antimicrobial website. Antibiotic prophylaxis is NOT routinely recommended in the following procedures: Assisted delivery Women s Antimicrobial Guidelines Summary Page 6 of 7
3. Education and Training Although no formal education and training is required: Medics working within neurology, microbiology, infectious diseases, and emergency & acute medicine should be made aware of this guideline All pharmacists should be made aware of this guideline Reference to this guideline will be made on the antimicrobial website and apps, and any relevant antimicrobial guidance and policies. 4. Monitoring Compliance What will be measured to monitor compliance Prescribing decisions and compliance with the guideline How will compliance be monitored Through an annual audit Monitoring Lead Audit lead for Obs & Gynae Frequency Annually Reporting arrangements Report to be sent to AWP 5. Supporting References None 6. Key Words Obstetrics, Gynaecology, Infection, Antibiotic CONTACT AND REVIEW DETAILS Guideline Lead (Name and Title): Executive Lead: Sharon Koo (Consultant microbiologist) Julie Smith (Director of Infection Prevention & Control) Additional Authors: Emma Cramp (Advanced Clinical Antimicrobial Pharmacist) Sonia Agarwal (Obstetric consultant) Details of Changes made during review: Addition of massive haemorrhage or bakri balloon to prophylaxis section. Infected perineal wound in line with primary care guidelines. Prophylaxis for third and fourth degree tears revised. Premature rupture of membranes updated. Bold text added to infection post removal of retained placenta. Intra-partum pyrexia updated to reflect Intra-partum pyrexia guideline. Surgical termination of pregnancy included. Additional information added to abscesses. Contact information added for GUM clinic. Women s Antimicrobial Guidelines Summary Page 7 of 7