CONSULTANT MICROBIOLOGIST

STANDARD OPERATING PROCEDURE: EMERGENCY FLO ANTIBIOTIC SOP SOP ID NUMBER TW10-136 SOP 4 VERSION NUMBER 8.1 APPROVING COMMITTEE DIVISIONAL QUALITY EXECUTIVE COMMITTEE (DQEC) - MEDICINE DATE VERSION APPROVED June 2016 RATIFYING COMMITTEE: DATE VERSION RATIFIED July 2016 DATE THIS VERSION AMENDED AUTH(S) PARC (Policy Approval and Ratification Committee) (February 2017) Page 13: Aspiration pneumonia section added. CONSULTANT MICROBIOLOGIST DIVISION/DIRECTATE ASSOCIATED TO WHICH POLICY? MEDICINE Antimicrobial Prescribing Policy TW10-136 Clostridium difficile Infection (CDI) Treatment for Adults TW10-042 SOP 13 Trust Antibiotic Treatment TW10-136 SOP 1 DATES PREVIOUS VERSION(S) RATIFIED Version: 1 2 3 4 5 5.1 5.2 6 7 7.1 7.2 7.3 8 DATE OF NEXT REVIEW July 2019 MANAGER RESPONSIBLE F REVIEW Date: June 2004 June 2006 November 2007 October 2009 August 2010 February 2011 March 2011 June 2011 May 2013 April 2014 March 2015 June 2015 June 2016 Your hospitals, your health, our priority

AT ALL TIMES, STAFF MUST TREAT EVERY INDIVIDUAL WITH RESPECT AND UPHOLD THEIR RIGHT TO PRIVACY AND DIGNITY. CONTENTS PAGE NUMBER 1. Statement 2 2. Key Principles 2 3. Limitations 2 4. Skin and Soft Tissue Infections 3 5. Hand and Finger Infections 5 6. Wounds and Lacerations 5 7. Bites and Stings 6 8. Ear Infections 7 9. Throat Infections 8 10. Orbital Cellulitis 10 11. Maxillo-Facial 11 12. Chest and Lower Respiratory Tract Infections 11 13. Diarrhoea 14 14. Urinary Tract Infection (UTI) 15 15. Genitourinary Infections 16 16. Trauma and Orthopaedics 16 17. Central Nervous System 17 18. Abdominal Infections 18 19. Sepsis Immunocompetent Host 18 20. Febrile Neutropenia 20 21. Prophylaxis 20 22. Human Rights Act 21 23. Accessibility Statement 21 APPENDICES PAGE NUMBER 1 References 22 2 Glossary of Terms 24 1

1. STATEMENT 1.1. This Standard Operating Procedure (SOP) incorporates information regarding appropriate selection, dosing, route and duration of antimicrobial therapy and prophylaxis for common conditions seen in the Accident and Emergency Department. 1.2. The primary goal of this SOP is to inform prescribers in order to optimise clinical outcome while minimising unintended consequences of antimicrobial use, including Clostridium difficile associated disease, toxicity and the emergence of resistance. 2. KEY PRINCIPLES 2.1. Send pus for culture and sensitivity only when you expect the management to be altered as a result of the test. 2.2. Ensure that any necessary specimens for microbiology are taken before commencing treatment. 2.3. All regimes are for 7 days unless stated otherwise. Doses are for adults. See the British National Formulary (BNF) for Children for childhood doses. 2.4. Wherever possible give antibiotics by the oral route. Intravenous antibiotics should be reserved for those patients who are unable to take tablets (unconscious/vomiting) or who are systemically unwell and/or present with a severe infection (meningitis, infective endocarditis, septicaemia). 2.5. Do not use antibiotics by the topical or intramuscular route. The former is ineffective (with the exception of some minor infections), and the latter is unduly painful for the patient. 2.6. Penicillin allergy. It is important to establish the true nature of a reported allergy to penicillin, as the alternative antibiotics may not be as effective or have a higher rate of side effects than penicillin. A history of rash or gastrointestinal symptoms with amoxicillin may not indicate true allergy. Unless signs of immediate type hypersensitivity (anaphylaxis, angiooedema, bronchospasm, urticaria) were reported, a trial with penicillin may be warranted. 2.7. Always ask about drug allergy and record details in the notes. Consider drug interactions, liver or renal impairment, pregnancy etc. Patients need clear instructions on how to take their antibiotic. 3. LIMITATIONS 3.1. This SOP is not intended to be comprehensive. Prescribers are advised to consult the BNF and the manufacturer s summary of product characteristics for additional information. This is especially relevant for side effects, contraindications, interactions with other drugs and the use of antimicrobials in pregnancy. 3.2. Advice about individual patients on clinical problems may be obtained from the Consultant Microbiologists: Dr C Faris extension: 2153 or Dr R Nelson ext 2943, or via switchboard outside normal working hours. 2

4. SKIN AND SOFT TISSUE INFECTIONS Abscess. Incision and drainage. Antibiotics are not indicated. Impetigo. Minor Lesions. Fusidic acid. Topically 6 hourly. Cellulitis. See: Community Parenteral Antibiotic Therapy and Formulary on Microbiology Intranet site. NB. Providing there is clinical improvement IVs should be continued until cellulitis subsides, then change to oral antibiotics for 5 further days. Cellulitis in patients with a history of Methicillin-resistant Staphylococcus aureus (MRSA) colonisation or risk factors such as several hospital colonisations within 6 months of nursing home residency. Necrotising fasciitis. If widespread. First line - Mild to Moderate: Outpatient management of severe cellulitis. Refer to Management of Cellulitis in Adults TW10-136 SOP 8 and Junior Doctors Guide to Antibiotic Treatment for Adults on the Policy Library. Severe/spreading with systemic symptoms: Admit ill patients for IV antibiotics: Prompt surgical debridement is essential, plus combination antibiotic treatment. Pressure relief and wound toilet only. Flucloxacillin oral clarithromycin oral. Flucloxacillin oral clarithromycin oral. Ceftriaxone intravenous (IV). Flucloxacillin IV teicoplanin IV. 1-2g daily. 1-2g 6 hourly. 400mg every 12 hours for 3 doses then 400mg once daily. Teicoplanin IV. 400mg every 12 hours for 3 doses then 400mg once daily. Tazocin IV plus clindamycin IV. 4.5g 8 hourly 900mg 6 hourly. Pressure sores Uncomplicated. Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling). 3

Pressure sores with progressing cellulitis. First line. Flucloxacillin IV (oral) ± metronidazole oral ceftriaxone IV ± metronidazole oral. 1g (500mg) 6 hrly 400mg 8 hourly. 1g once daily 400mg 8 hourly. Pressure sores with progressing cellulitis and systemic symptoms. Diabetic foot Mild infection Cellulitis/erythema < 2cm AND infection limited to skin or superficial subcutaneous tissue AND NO PREVIOUS antibiotic treatment. Diabetic foot Moderate infection Cellulitis extending >2cm Lymphangitis Deep tissue abscess failure of previous antibiotic. Diabetic foot Severe infection with systemic symptoms (fever, white blood cell (WBC), C-reactive protein (CRP)), necrosis or osteomyelitis. First line. First line. Polymicrobial infections. Debridement indicated. Tazocin IV. Add teicoplanin if at highrisk of MRSA*. Flucloxacillin oral or IV clindamycin oral. Co-amoxiclav IV (oral) If allergic to penicillin, clindamycin IV (oral) plus ciprofloxacin IV (oral). Tazocin IV plus clindamycin IV If allergic to penicillin, ciprofloxacin IV (oral) plus clindamycin IV (oral). 4.5g 8 hourly. 1g 6 hourly. 450mg 6 hourly. 1.2g (625mg) 8 hourly. 600mg (oral 450mg) 6 hourly 400mg (oral 750mg) 12 hourly. 4.5g 8 hourly. 900mg 6 hourly. 400mg (oral 750mg) 12 hourly 900mg (oral 450mg) 6 hourly. 7-14 days. Parenteral therapy until stable then oral antibiotics for up to 4 weeks in the absence of osteomyelitis. 2-4 weeks. * Previous MRSA, hospital admissions within 6 months, nursing home resident. Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling). IV therapy until stable, then oral antibiotics for 2 to 4 weeks in the absence of osteomyelitis. Note: < = less than > = greater than < = less than or equal to > = greater than or equal to ± = plus minus (See Appendix 2 for glossary of terms). 4

5. HAND AND FINGER INFECTIONS Acute paronychia. Incision and drainage. Antibiotics usually not necessary. Pulp space infection. X-ray to exclude osteomyelitis. Incision and drainage under ring or wrist block. A wide elliptical incision is required. Review in Accident and Emergency Clinic after 48 hours. Antibiotics usually not necessary. Web space infection. Urgent referral to Orthopaedic Surgeons. Deep palmar space. Urgent referral to Orthopaedic Surgeons. Suppurative tenosynovitis. Urgent referral to Orthopaedic Surgeons. 6. WOUNDS AND LACERATIONS Less than 6 hours old. NO ANTIBIOTICS Clean, debride and do Primary Closure. Delayed presentation. Consider antitetanus vaccination. If cellulitis is present treat with flucloxacillin. Flucloxacillin oral clarithromycin oral. Puncture wounds. Consider anti-tetanus vaccination. Flucloxacillin oral clarithromycin oral. Wound infections. No cellulitis equals No antibiotics. Consider antitetanus vaccination. 7 days 5

7. BITES AND STINGS Animal bites. Adult: First line: Surgical toilet most important. Assess tetanus and rabies risk. Antibiotic prophylaxis may not be indicated for all cases. Antibiotic prophylaxis advised for puncture wound, bite involving hand, foot, face, joint, tendon, ligament, immunocompromised, diabetic, elderly, asplenic. Co-amoxiclav oral ciprofloxacin oral plus clindamycin oral. 625mg 8 hourly. 450mg 6 hourly. Child <6 years: Co-amoxiclav oral. seek Microbiology advice. 125/31 SF suspension 5ml 8 hourly or 0.25ml/kg 8 hourly. Human bites. 6-12 years: Antibiotic prophylaxis advised. Assess Human Immunodeficiency Virus (HIV)/ hepatitis B and C risk. Co-amoxiclav oral. See above. 250/62 SF suspension 5ml 8 hourly or 0.15ml/kg 8 hourly. Insect bites. Treat only if clinically infected. Flucloxacillin oral clarithromycin oral. 6

8. EAR INFECTIONS Acute otitis Media (OAM). Otitis media (OM) resolves in 60% in 24hrs without antibiotics. 500mg 8 hourly. Acute otitis externa (diffuse). Aural toilet and analgesia recommended. Necrotising/Malignant otitis externa (Pseudomonas). Consider antibiotics if <2yrs and bilateral AOM; all ages with otorrhoea. Optimise analgesics and target antibiotics. Mild: Moderate: (Cellulitis or disease extending outside ear canal). Amoxicillin oral Co-amoxiclav oral if previously failed on amoxicillin. Clarithromycin oral. Acetic acid 2%. Neomycin sulphate with corticoid steroid any other topical drops at the discretion of the Ear Nose and Throat Consultant. Topical antibiotics plus Flucloxacillin oral. Topical antibiotics plus Clarithromycin oral. Tazocin IV plus topical treatment. 625mg 8 hourly. 1 spray 8 hourly. 3 drops 8 hourly. 4.5g 8 hourly. 4-6 weeks. Ciprofloxacin plus Clindamycin. Discuss with a Microbiologist. 750mg 12 hourly. 450 mg 6 hourly. 7

Acute Mastoiditis. Cefuroxime IV plus 1.5g 8 hourly. 24-48 hours. Metronidazole IV. 500mg 8 hourly. Co-amoxiclav. 625mg 8 hourly. 10-14 days. Traumatic rupture of tympanic membrane. Discuss with a Microbiologist. Flucloxacillin oral. clarithromycin oral. 9. THROAT INFECTIONS Tonsillitis. Antibiotic is recommended only for patients who have three or four criteria (Centor). History of fever. Tonsillar exudate. Absence of cough. Tender anterior cervical lymphadenopathy. Or are immunosuppressed. Or have valvular heart disease. Mild: Penicillin V oral. Clarithromycin oral. Severe: Benzyl Penicillin IV. Penicillin V. Clarithromycin IV. 1.2g 6 hourly. 10 days. 10 days. 10 days. 10 days. Clarithromycin PO. 8

Quinsy. (Peri-tonsillar Abscess). Incision and drainage. Benzyl Penicillin IV plus Metronidazole IV. Co-amoxiclav. 1.2g 6 hourly. 500mg 8 hourly. 625mg 8 hourly. 10 days. 10 days. Clindamycin IV. 900mg 6 hourly. Parapharyngeal Abscess. Clindamycin. Ceftriaxone IV plus Metronidazole. 450mg 6 hourly. 2g once daily. 500mg 8 hourly. 10-14 days. Co-amoxiclav. 625mg 8 hourly. Ciprofloxacin oral plus Clindamycin IV. 750mg 12 hourly. 900mg 6 hourly. 10-14 days. Parotitis (Suppurative). Ciprofloxacin plus Clindamycin. Mild: Flucloxacillin oral. 750mg 12 hourly. 450mg 6 hourly. Clarithromycin oral. Severe: Flucloxacillin IV. 1g 6 hourly. Flucloxacillin. Clarithromycin IV. 500mg 12 hourly Clarithromycin PO. 9

Epiglottitis. Ceftriaxone IV. 2g once daily. 24-48 hours. Co-amoxiclav. 625mg 8 hourly. Ciprofloxacin IV plus Clindamycin IV. 400mg (or oral 750mg) 12 hourly 900mg 6 hourly. 7-10 days. Acute bacterial sinusitis. Ciprofloxacin plus Clindamycin. Amoxicillin oral. 750mg 12 hourly. 450mg 6 hourly. 500mg 8 hourly. Doxycycline oral. 200mg stat day 1 then 100mg 12 hourly. 10. BITAL CELLULITIS Peri-orbital cellulitis. Refer to Ophthalmology Department immediately for children, use doses at higher end of cefuroxime dosage range. Cefuroxime IV plus Metronidazole IV. Co-amoxiclav. 1.5g 8 hourly. 500mg 8 hourly. 625mg 8 hourly. 14 days. 24-48 hours. Ciprofloxacin oral plus Clindamycin IV. Ciprofloxacin plus Clindamycin. 750mg 12 hourly. 900mg 6 hourly. 750mg 12 hourly. 450mg 6 hourly. 14 days. 10

11. MAXILLO-FACIAL Fractures of maxilla. Dental infection/abscess. First line: Abscess will need drainage. Refer. Co-amoxiclav oral clarithromycin oral. Penicillin V oral metronidazole oral. 375mg 8 hourly. 400mg 8 hourly. 12. CHEST AND LOWER RESPIRATY TRACT INFECTIONS Croup. Laryngitis. Tracheitis. Infective bronchitis in healthy adults. Infective exacerbations of Chronic Obstructive Pulmonary Disease (COPD). Most are viral. No antibiotics indicated. Most are viral. No antibiotics indicated. Most are viral. No antibiotics indicated. Most are viral. No antibiotics indicated. Consider if antibiotics are needed. Doxycycline oral 200mg stat on day 1 then 100mg 12 hourly. 6 days. Non-pneumonic chest infections (both community and hospital acquired). Antibiotics indicated if 2 or more of the following: increase in purulence of sputum; increase in volume of sputum; increase in breathlessness. Most valuable if increased dyspnoea and purulent sputum. Patient not responding to or failed a recent course of doxycycline. If nil by mouth. trimethoprim oral. co-amoxiclav oral. co-amoxiclav IV. 200mg 12 hourly. 625mg 8 hourly. 1.2g 8 hourly. If consolidation on CXR treat as for pneumonia (see below). Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling). 11

Community-acquired pneumonia (CAP). CURB 65 = 0-1. Amoxicillin oral 500mg 8 hourly. Evidence of consolidation on CXR. Clinical findings and severity rating using CURB-65 score must be documented: doxycycline oral. 200mg stat on day 1 then 100mg 12 hourly. 4 days. C = New confusion (AMTS<8) 1 point. clarithromycin oral. U = Urea >7 1 point. Children less than 6 months: treat as R = Respiratory Rate >30 1 point. for severe CAP. B = SBP <90 or DBP <60 1 point. 6 months - 5 years: Amoxicillin oral 65 = Age >65 1 point. 5 years 18 years: Clarithromycin oral/iv. Community-acquired pneumonia. CURB 65 = 2. Amoxicillin (oral or IV) Plus clarithromycin oral ceftriaxone IV plus clarithromycin (oral or IV). Severe Community-acquired pneumonia. Collect sputum and blood cultures if pyrexial. Legionella and pneumococcal urinary antigen and nose and throat swabs (VTM) for respiratory viruses. All patients with pneumonia should receive treatment within one hour of diagnosis. Post Influenza pneumonia. CURB 65 3-5. Neonates and children less than 6 months: 6 months - 18 years (atypical pathogens more common in over 5 years). Co-amoxiclav IV Plus clarithromycin (IV or oral) ceftriaxone IV Plus clarithromycin (IV or oral). Cefuroxime IV monotherapy. Cefuroxime IV ± clarithromycin. Flucloxacillin IV plus amoxicillin IV clindamycin IV. Consult BNFc for dosage instructions. 500mg 1g 8 hourly. 1g once daily. 1.2g 8 hourly. 1-2g once daily. Consult BNFc for dosage instructions. 2g 6 hourly. 1g 8 hourly. 600mg 6 hourly. 7-14 days. 7 10 days. 7 10 days. 7 10 days. 7 10 days. 7-14 days. 10 days. 10 days. 10 days. 12

Community acquired aspiration 1.2g 6 hourly. pneumonia. 500mg 8 hourly. HOSPITAL ACQUIRED PNEUMONIA: Pneumonia diagnosed more than 5 days from admission. Patients admitted from Nursing Homes do not need to be treated as HAP unless they meet the criteria. Benzylpenicillin IV plus metronidazole IV ceftriaxone IV plus metronidazole IV. 1g once daily. 500mg 8 hourly. Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling). 13

13. DIARRHOEA Viruses. Salmonella sp. Campylobacter sp. Shigella sp. Severe diarrhoea (> 6 unformed stools/day, and/or pyrexia, tenesmus, blood in stool). Clostridium difficile infection (CDI) Review concurrent antibiotic treatment, PPIs or laxatives and discontinue them where possible. For full details, please refer to Clostridium difficile infection: Treatment TW10-042 SOP 13. Antibiotic therapy is not usually recommended for cases with mild or moderate diarrhoea. Infection prevention and control procedures should be followed in all cases to reduce cross infection (isolation). Campylobacter or shigella suspected. Ciprofloxacin oral. Initial episode in patient age <75 years with NO severe co-morbidities. Initial episode in patient age 75 years and/or with severe comorbidities (immunocompromised, organ failure). Metronidazole oral/nasogastric (NG). If oral route is compromised: Metronidazole IV. Vancomycin oral/ng. 400mg 8 hourly. 500mg 8 hourly. 125mg 6 hourly. 10-14 days. 10-14 days. 10-14 days. Severe CDI. Life threatening CDI (hypotension, partial or complete ileus or toxic megacolon or CT evidence of severe disease). If ileus is present, then add vancomycin as a retention enema (500mg in 100ml normal saline per rectum 6 12 hourly). Vancomycin oral/ng. If no clinical response, vancomycin dose may be increased. If oral route is compromised: Metronidazole IV plus intracolonic vancomycin. Vancomycin (NG tube). Vancomycin oral/ng plus metronidazole IV. 125mg 6 hourly. 500mg 8 hourly. 500mg in 100ml of normal saline every 6 to 12 hours. 500mg 8 hourly. 10-14 days. 10-14 days. 10 14 days. 14

14. URINARY TRACT INFECTION (UTI) Condition Regimen Penicillin allergy/ Alternative regimens Uncomplicated lower UTI. Nitrofurantoin # oral 50mg 6 hourly for 3-7 daysŧ. Patient with egfr < 45ml/min, co-amoxiclav oral 375mg 8 hourly for 3-7 daysŧ. UTI in children. Complicated UTI/Pyelonephritis. Factors suggesting a complicated UTI: Trimethoprim 5 - Consult BNFc for dosage instructions. Cefalexin oral 500mg 12 hourly for 3-7 daysŧ. Male patients, pregnant, diabetes mellitus, renal tract abnormalities, recent urinary surgery/instrumentation (excluding urinary tract catheterisation), indwelling urinary catheter, symptoms persisting for over 7 days, recent broad spectrum antibiotics. Severely ill child. Severe sepsis associated with UTI. Catheter-associated UTI (CAUTI). Empirical co-amoxiclav oral 625mg (or IV 1.2g) 8 hourly + IV gentamicin* 7mg/kg/day (max dose 560mg). Duration of treatment: for complicated UTI: 7 days for pyelonephritis: 14 days. Gentamicin indicated if there are concerns of multi-drug resistant organisms. Ceftriaxone IV for 7 14 days. Consult BNFc for dosage instructions. Tazocin IV 4.5g 8 hourly + IV gentamicin* 7mg/kg/day (max dose 560mg). Known sensitivity trimethoprim oral 200mg 12 hourly. Duration of treatment: 10 days. Ceftriaxone IV 1-2g once daily + IV gentamicin* 7mg/kg/day (max dose 560mg). All catheters become colonised by bacteria and growth of organisms from a CSU is NOT an indication for antibiotic treatment in the absence of clinical evidence of infection. DO NOT DIPSTIX ON CSUs. Symptoms suggestive of CAUTI New loin or suprapubic tenderness Rigors New onset delirium Fever >38 o C or 1.5 o C above baseline on two occasions during 12 hours. Send urine for culture only if clinically indicted by above symptoms. Obtain sample from new catheter and await culture results if possible. CAUTI with systemic features of sepsis (Systemically unwell 2 or more of following: Temperature>38 or <36, HR >90, RR>20, WBC >12 or <4). Co-amoxiclav PO 625mg 8 hourly + gentamicin* IV 7mg/kg/day (max 560mg). Duration of treatment: Gentamicin indicated if there are concerns of multi-drug resistant organisms. IV tazocin 4.5g 8 hourly + IV gentamicin* 7mg/kg/day (max dose 560mg). # Nitrofurantoin - Contraindicated if egfr <45ml/min. Ŧ For uncomplicated cystitis in women without a catheter, give 3 day course; for all other patients give Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling). * /Antimicrobial Pharmacist for dosing advice for patients with renal failure. 15

15 GENITOURINARY INFECTIONS Epididymo-orchitis. Age < 35yrs. Ceftriaxone IM or IV plus doxycycline oral. 500mg stat dose. 100mg 12 hourly. 10-14 days. Age > 35yrs. Ciprofloxacin oral. 10 days. Prostatitis. Ciprofloxacin oral. 28 days. Pelvic Inflammatory Disease. Empirical treatment: Do full investigation including endocervical swabs for Chlamydia and gonorrhoea. Arrange follow-up with GUM clinic 01942 483188. If pregnancy test negative: Ceftriaxone IM or IV Doxycycline oral plus metronidazole oral. If pregnancy test positive: Seek Microbiology advice. 500mg stat dose. 100mg 12 hourly. 400mg 12 hourly. Consult Microbiologist or Antimicrobial Pharmacist for dosing advice for patients with renal failure. Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (for example:. anaphylaxis, angioedema, facial/throat swelling). 14 days. 14 days. 16 TRAUMA AND THOPAEDICS Acute septic arthritis and osteomyelitis. Ideally blood cultures, joint aspirates or biopsy material should be taken prior to starting antibiotics. IV antibiotics are indicated for minimum 2 weeks. Child: Flucloxacillin IV plus gentamicin IV teicoplanin IV. plus Gentamicin IV. 2g 4-6 hourly 7mg/kg once-daily (max dose 560mg). 10-12mg/kg 12 hourly for three doses then same dose once daily 7mg/kg once-daily (max dose 560mg). 42 days. Flucloxacillin plus amoxicillin Cefuroxime. See BNF for Children for dosage information. 16

Compound fractures. Consider tetanus vaccine. Co-amoxiclav IV. 1.2g 8 hourly. 1-2 days. teicoplanin IV. ± gentamicin IV. Plus metronidazole IV. Consult Microbiologist or Antimicrobial Pharmacist for dosing advice for patients with renal failure. 400mg 12 hourly. 1.5mg/kg 12hourly. 500mg 8 hourly. 3 doses. 1-2 days. 1-2 days. 17 CENTRAL NERVOUS SYSTEM Meningitis. Neonates (0-3 months). Cefotaxime IV plus amoxicillin IV. See BNF for Children for dosage information. Variable according to pathogen. Encephalitis. 3 month 18 years. Adults: If over 50 years of age, pregnant or immunocompromised, consider Listeria (add amoxicillin 2g 4 hourly). Consider ciprofloxacin prophylaxis for contacts of cases with meningococcal meningitis. Mostly viral. Ceftriaxone IV. Ceftriaxone IV. Seek Microbiology advice. 2g 12 hourly. Herpes simplex encephalitis. Aciclovir IV. 10mg/kg 8 hourly. 14-21 days. 17

18 ABDOMINAL INFECTIONS Acute appendicitis. Perforated abdominal viscus. Localised abdominal abscess. Generalised peritonitis. Cholecystitis, Cholangitis. Diverticulitis. Antibiotics are NOT indicated for uncomplicated cases but should be given if patient is unwell and/or septic. Co-amoxiclav IV Tigecycline IV. Co-amoxiclav IV Tigecycline IV. Tazocin IV Tigecycline IV. Tazocin IV. Tigecycline IV. 1.2g 8 hourly. 100mg once then 50mg 12 hourly. 1.2g 8 hourly. 100mg once then 50mg 12 hourly. 4.5g 8 hourly. 100mg then 50mg 12 hourly. 4.5g 8 hourly. 100mg then 50mg 12 hourly. Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling). 19 SEPSIS IMMUNOCOMPETENT HOST No obvious focus of infection. Add teicoplanin if at high risk of MRSA*. Tazocin IV + gentamicin IV 4.5g 8 hourly 7mg/kg once-daily (max dose 560mg). 7-14 days. teicoplanin IV for 3 doses then once daily plus gentamicin IV plus metronidazole IV. Associated with intra-abdominal source. Tazocin IV + gentamicin IV Consult Microbiologist or Antimicrobial Pharmacist for dosing advice for patients with renal failure. tigecycline IV AND gentamicin IV. 10-12mg/kg 12 hourly. 7mg/kg/day (max dose 560mg) 500mg 8 hourly. 4.5g 8 hourly 7mg/kg once-daily (max dose 560mg). 100mg once then 50mg 12 hourly 7mg/kg once-daily (max dose 560mg). 18

Associated with soft tissue/ skin infections. Flucloxacillin IV teicoplanin IV. Associated with urinary tract. Tazocin IV + gentamicin IV ceftriaxone IV ± gentamicin IV. Associated with chest infection. Septicaemia in IV drug users. Neonatal sepsis (< 3 months). Septicaemia in children (3 months 18 years). See recommendations for severe CAP or Hospital acquired pneumonia (HAP). Group B Streptococcus (GBS) suspected. Listeria, GBS or coliforms suspected. Flucloxacillin IV plus gentamicin IV. Benzylpenicillin IV plus gentamicin IV Amoxicillin IV plus cefotaxime IV. Ceftriaxone IV. 1-2g 6 hourly. 600mg 12 hourly for 3 doses then 600mg daily. 4.5g 8 hourly 7mg/kg oncedaily (max dose 560mg). 1-2g once daily 7mg/kg oncedaily (max dose 560mg). 2g 6 hourly 7mg/kg oncedaily (max dose 560mg). See BNF for Children for dosage information. See BNF for Children for dosage information. * Previous MRSA, hospital admissions within 6 months, nursing home resident. Consult Microbiologist or Antimicrobial Pharmacist for dosing advice for patients with renal failure. Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling). 7-14 days. 7-14 days. 7-14 days. 19

20 FEBRILE NEUTROPENIA Low-risk patient. Refer to full Management of Adults with Neutropenic Sepsis TW11-006 SOP. Co-amoxiclav oral plus ciprofloxacin oral. 625mg 8 hourly. 750mg 12 hourly. High-risk patient. Indications for teicoplanin: severe mucositis, history of ciprofloxacin prophylaxis, IV catheter sepsis, known/suspected MRSA colonisation. Meropenem IV +/- teicoplanin IV. If penicillin allergic seek microbiology advice. 1g 8 hourly 10mg/kg 12 hourly for 3 doses, then 10mg/kg once-daily. 21 PROPHYLAXIS Prevention of infective endocarditis. Prevention of secondary cases of meningococcal disease. HIV Post exposure prophylaxis. Hepatitis B prophylaxis following percutaneous injury. Refer to Antibiotic Prophylaxis for Splenectomy, Meningococcal disease, H Influenzae type b disease and Endocarditis. TW10-136 SOP 2. Adult and children over 12 years. Pregnancy. Children 5-12 years. Children 1 month to 4 years. If ciprofloxacin is contraindicated consider Rifampicin. Refer to Post exposure Prophylaxis for Health Care Workers Occupationally Exposed to HIV TW10-042 SOP 2. Refer to Post Exposure Prophylaxis for HIV following Non- Occupational Needle Stick or Bite Injury TW10-042 SOP 47. Refer to Post exposure Prophylaxis for Health Care Workers Occupationally Exposed to HIV TW10-042 SOP 2. Refer to Post Exposure Prophylaxis for HIV following Non- Occupational Needle Stick or Bite Injury TW10-042 SOP 47. Ciprofloxacin oral. Truvada (containing 300mg tenofovir plus 200mg emtricitabine) plus Raltegravir. 500mg. 500mg. 250mg. 125mg. One tablet once daily. 400mg 12 hourly. STAT. 28 days. Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling). 20

22. HUMAN RIGHTS ACT Implications of the Human Rights Act have been taken into account in the formulation of this policy and they have, where appropriate, been fully reflected in its wording. 23. ACCESSIBILITY STATEMENT This document can be made available in a range of alternative formats e.g. large print, Braille and audio cd. For more details please contact Human Resources Department on 01942 77(3766) or email equalityanddiversity@wwl.nhs.uk 21

REFERENCES: Emergency Floor Antibiotic SOP - Version 8.1 APPENDIX 1 BNF 66; March September 2013. Infections; 338-442. BNF for Children, 2013-2014. Infections; 244-348. Bone and Joint Infection: Anon. The Management of Septic Arthritis. Drug and Therapeutics Bulletin, 2003; 41:65-68. Bone and Joint Infections in: Antibiotic and Chemotherapy. Edited by O Grady F, Lambert H, Finch RG, Greenwood D. 7 th Ed, Churchill Livingstone, Edinburgh 1997. CNS Infection: McGrath N, Andeson NE, Croxson Mc and Powell KF. Herpes simplex encephalitis treated with acyclovir, diagnosis and long term outcome. J Neurol Neurosurg Psychiatry, 1997; 63: 321-326. Heydermnan RS, Lamber HP, O Sullivan I, et al. Early Management of Suspected Bacterial Meningitis and Meningococcal Septicaemia in Adults. Journal of Infection, 2003; 46(2): 75-77. British Infection Society. Consensus statement on diagnosis, investigation, treatment and prevention of acute bacterial meningitis in immunocompetent adults. Journal of Infection 1999; 39; 1-15. Gastrointestinal Infection: British Society for the Study of Infection. The Management of Infective Gastroenteritis in Adults. Journal of Infection. 1996; 33: 143-152. Genitourinary Infection: Anon. Guideline No.32: Management of Acute Pelvic Inflammatory Disease. Royal College of Obstetricians and Gynaecologists, London 2003. Foster G. Treatment of pelvic inflammatory disease in primary care. Prescriber s Journal. 1998; Vol. 38 No. 2. Anon. SIGN 88. Management of suspected bacterial urinary tract infections in adults, July 2012. Respiratory Infection: Anthonisen MD, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson A. Antibiotic Therapy in Exacerbations of Chronic Obstructive Pulmonary Disease. Annals of Internal Medicine, 1987; 106: 196-204. Anon. British Thoracic Society Guidelines on Management of Community-acquired Pneumonia in Adults. Thorax, 2001; 56 (suppl 4) - 2004 Update and 2009 Update. Kozyrski AL, Hildes Ristein E, Longstaffe SEA, Wincott JL, Sitar DS, Klassen TP. Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis. JAMA, 1998; 279: 1736-1742. O Neill P and Roberts R. Acute Otitis Media, in Clinical Evidence, London, BMJ Publishing Group, 2003; 9: 274-286. 22

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APPENDIX 2 GLOSSARY OF TERMS ATMS BNF BNFc CAP CAUTI COPD CRP CSU CT CURB 65 CXR DBP egfr GUM HAP HIV HR IM IV KG MG ML MRSA NG OD PO QDS RR SBP STAT TDS UTI VTM WBC Ataxia Telangiectasia Mutated British National Formulary British National Formulary for children Community acquired pneumonia Catheter-associated UTI Chronic obstructive pulmonary disease C-reactive protein Catheter specimen urine Computerised tomography Index for measuring severity of CAP by assessing for presence of Confusion, serum urea, respiratory rate, blood pressure and age Chest x-ray Diastolic blood pressure Estimated glomerular filtration rate Genito-urinary Medicine Hospital acquired pneumonia Human immunodeficiency virus Heart rate Internal medicine Intravenous Kilogram Milligram Millilitre Methicillin resistant staphylococcus aureus Nasogastric Once a day By mouth Four times a day Respiratory rate Systolic blood pressure Immediately Three times a day Urinary tract infection Viral transport medium White blood cell 24