How to contact Microbiology / Infectious Diseases / Pharmacy

Galway University Hospital (GUH)

Microbiology

Consultants: Prof. Martin Cormican, Dr. Úna Ní Riain, Dr. Deirbhile Keady, Dr. Teck Wee Boo, Dr. Dimitar Nashev, Dr. Ruth Waldron, Dr. Roisin Mulqueen (contact through the hospital switch board)
Microbiology Registrars: 4573 / 2643 / 8738

Infectious Diseases (ID)

Consultants: Dr. Catherine Fleming, Dr. Helen Tuite, Dr. David Gallagher, Dr. Geraldine Moloney, Dr. Andrea Holmes, Dr. Eibhlin Higgins (contact through the hospital switch board)
ID Registrars: 2210 / Bleep 671

Pharmacy

Antimicrobial Pharmacists: Ms. Ciara Lang and Ms. Orla Fahy 2150 Bleep 503
Infectious Diseases Pharmacist: Ms. Katie McDonough Bleep 629
Pharmacy dispensary UHG: 4651 / 4205 Merlin Park: 5682 / 5378

GUH Out of Hours: A Consultant Microbiologist is on call 24 hours per day 7 days per week and can be contacted through the hospital switch board. In general, out of hours, the Consultant Microbiologist should be contacted by the appropriate Registrar or Consultant.

Mayo University Hospital (MUH)

Microbiology Consultants: Dr. Shomik Sibartie 1335, Dr Leonardo Nieto-Aponte 2138 (or via MUH switch board)
Microbiology registrar: 2137
Antimicrobial Pharmacist: Bleep 630
Pharmacy Dispensary: 2192 / 2193 (opening hours of the pharmacy dispensary 8:30am-4:30pm, contact nursing admin bleep 607 outside of Pharmacy opening hours)
Out of hours: Microbiology Consultant on call via MUH switch board

Portiuncula University Hospital (PUH)

Microbiology Specialist Registrar: 091 544573 or 091 542643 or 091 548738
Out of hours (or if Specialist registrars not available) Microbiology Consultant: via Reception in Portiuncula - 24/7 Registrar/Consultant only
Antimicrobial Pharmacist: Extn 4781
Pharmacy Dispensary Portiuncula: 8221

Roscommon University Hospital (RUH)

Microbiology Specialist Registrar: 091 544573 or 091 542643 or 091 548738
Out of hours (or if Specialist registrars not available): See GUH Out of hours above
Pharmacy Dispensary Roscommon: 2279

Guideline Development Group

Development of these guidelines was led by a group comprised Dr. Ú. Ní Riain, Ms. C. Lang, Ms. O. Fahy, Dr. T. Boo, Prof. M. Cormican, Dr. C. Fleming, Dr. H. Tuite, Dr. D. Gallagher, Dr. D. Keady, Dr. G. Moloney, Dr. R. Mulqueen, Dr. E. Higgins, Dr R. Waldron, Dr. D. Nashev, Dr. A. Holmes, Dr. C. Mulrooney, Dr. S. Gregg, Dr. M. Leonard, Ms. S. George, Ms. T. Matthews and Ms. K. McDonough. The guidelines initially developed by Prof. M. Cormican in 2004 have been revised and expanded every two-three years. The guidelines are based on national and international guidelines, local microbiological data and expert opinion.

During the consultation process, contributions and suggestions were received from colleagues, including Ms. S. O Regan, Ms. Rose Cafferkey and Dr Shomik Sibartie. The group would like to acknowledge any others not mentioned, for contributions to preparation and review of these guidelines, particularly Marie Tierney for historical contribution. Comments or suggestions for improvement for future editions can be sent by email to Dr. Úna Ní Riain at una.niriain@hse.ie or Ms.Ciara Lang at ciarae.lang@hse.ie

The guidelines have been approved by Galway University Hospitals (GUH) Drug and Therapeutics Committee. See GUH useful resources https://web.medicaleguides.com/public/guh for the most up-to-date electronic version of these guidelines.

The guidelines are available as an application for Smartphones (Apple and Android), with built-in dosing calculators for gentamicin, tobramycin and vancomycin. The GAPP App (hosted by MEG eguides) provides automatic updates to ensure access to the most recent version of the guidelines.

Effective from: July 2024

Review Date: July 2027

Statement of Purpose and Limitations

This document relates primarily to common conditions or to conditions that are uncommon but associated with serious morbidity or mortality. It is intentional that this empiric guideline document presents minimal background and explanation.

Dosage and dose intervals as specified are for adults with normal renal and hepatic function. There is a separate section for dosing in renal impairment. Although certain specific adverse effects are referred to, issues of adverse effects, drug interactions and contraindications are not addressed in detail. They should be checked in appropriate sources such as the manufacturer’s licensed product information in the Summary of Product Characteristics (SPC) available at HPRA.ie and the British National Formulary (BNF).

Prescribers must use their professional judgement to identify circumstances in which there are specific reasons why this general guidance is not appropriate. In such circumstances please discuss treatment with the Departments of Microbiology, Infectious Diseases or Pharmacy.

These empiric guidelines are designed in line with best practice in antimicrobial prescribing and with national and international guidelines on antimicrobial stewardship. As such, they support optimal antimicrobial use in GUH. Optimal antimicrobial use means that patients receive the right antimicrobial therapy at the right dose, route and duration, and for the right infection type at the right time, while minimising the risk of development of resistance.

These guidelines are intended for initial empiric therapy. Empiric treatment is choice of antimicrobial prior to susceptibility results being available.
Regular review of the patient’s progress is essential and treatment should be reviewed in the light of changes in clinical condition.
If a specific pathogen(s) is identified, the treatment should be reviewed. The least toxic, narrowest spectrum and least expensive agent or combination of agents that is effective should be used for the treatment of specific pathogens.
Usual recommended duration of therapy is included for many conditions, and assumes there is satisfactory clinical progress and response to therapy – clearly if clinical progress is slow or not satisfactory then individual patient management, including the duration of therapy, should be reviewed and discussed with Microbiology or Infectious Diseases if required.
It may be possible to switch from IV to oral therapy after 24 to 48 hours.
Please discuss duration of therapy and potential for switch from IV to oral therapy with Microbiology or Infectious Diseases or Pharmacy if required.

GUH have agreement to use the Children's Health Ireland (CHI) Antimicrobial Guidelines for patients less than 18 years old. The guidelines are available as part of the CHI Paediatric Formulary app (Clinibee). The CHI website can be accessed via link . You may be asked to register an account using your email address. The lead contact is Dr. Edina Moylett.

GUH Disclaimer

The GUH Antimicrobial Guidelines (GAPP) are being shared on the strict understanding that these guidelines were prepared for use by healthcare professionals in Galway University Hospital (GUH), Portiuncula University Hospital (PUH), Roscommon University Hospital (RUH) and Mayo University Hospital (MUH) only. Any use of part, or all, of these guidelines outside of GUH, PUH, RUH and MUH is conditional on them being reviewed by appropriate clinicians /management. No liability whatsoever shall attach to GUH for the use of part, or all, of these guidelines outside of GUH, PUH, RUH and MUH.

These guidelines are intended to guide and facilitate the care of patients at GUH, PUH, RUH, and MUH. The guidance contained therein is not intended to replace individual assessment and personalised treatment of the patient. The authors have made every reasonable effort to base the guidance on best available evidence and to ensure accuracy of content at the time of going to press. However technical and clinical information changes rapidly and it is not possible to guarantee that all items will be accurate at all times. The application of the information in this guideline in clinical situations remains the professional responsibility of the practitioner.

GUH Pharmacy Resources

Access pharmacy inTERnet site at Home | Medinfo Galway for GUH Intravenous Medicines Administration Guide. Monographs are available for all intravenous medicines, including antimicrobials, in use in the hospital. Please consult the guide for information on safe prescription and administration of intravenous medicines.

Additional information including Pharmacy reference sources e.g. Medicines Complete, BNF, BNF for Children, The Renal Drug Database are available on inTRAnet site via hospital network computers only at http://medinfogalway/

Contact Pharmacy Department for additional information and advice (see How to contact Microbiology / Infectious Diseases / Pharmacy section above).

Changes for this Edition

Changes to this Edition

Significant Changes Version 11 2024 (Significant changes in red)
Section	Significant Change
Prescribing Principles	New sections on; dosing in obesity, understanding antimicrobial susceptibility test reports and Vancomycin Resistant Enterococcus (VRE).
Reserve Antimicrobials	Update Reserve Antimicrobial policy Pharmacy Algorithm for supply of red light antimicrobials in GUH
IV to Oral Switch Therapy	Add * Reasons to avoid/delay switching- Some cases may be suitable for IV to PO switch under Micro/ID Addition Please discuss switch from IV to oral clindamycin with Micro/ID
Aminoglycoside and Vancomycin Dosing and Monitoring	The definition/rule for obesity changed; Patient is considered obese when the Actual Body Weight is ≥20% above IBW. The Gentamicin calculator has been automatically updated. Standardised wording around patients who require vancomycin loading doses to include complicated infections. Change in wording from if haemodynamically unstable to if sepsis.
1. Abdomen	Spontaneous Bacterial peritonitis - Add Gentamicin IV If sepsis.
2. Bone and Joint	Included in the introduction, patients with sepsis antibiotic therapy should not be delayed while awaiting bone or synovial fluid sampling. Septic arthritis broken out into three rows, native joint, MRSA risk factors and risk of gonococcal infection/high risk of Gram-negative organisms. First line antibiotics for septic arthritis in penicillin allergy changed to CeFAZolin in non-severe allergy and Vancomycin for severe allergy. Antibiotics for MRSA risk factors Vancomycin. Added comment for osteomyelitis that short course or PO antibiotics may be appropriate for acute on chronic infection.
3. Cardiovascular	Prophylaxis for dental procedures changed for patients with penicillin allergy. Doxycycline PO recommended for penicillin allergy. For those unable to take oral medication group divided into IV cefTRIAXone for delayed onset non severe reaction requiring prophylaxis or clindamycin IV prophylaxis for immediate/severe delayed onset reaction.
4. CNS	Wording changed for suspected bacterial meningitis, consider adding vancomycin if pneumococcal meningitis is likely/suspected. Footnote * re Dexamethasone included. Dose changed to dexamethasone 10mg IV rather than weight based dosing. Discontinue dexamethasone if a diagnosis other than bacterial meningitis is subsequently made. Discontinue dexamethasone if bacterial meningitis with an organism other than pneumococcus or H.influenzae meningitis is confirmed. Added comment in the introduction for viral meningitis (as distinct from encephalitis) generally does NOT require anti-viral treatment. Discuss with Micro/ID.
5. Eye	Add red flag features that should trigger a same day referral to Ophthalmology. Change to chloramphenicol dosing for Acute Bacterial Conjunctivitis. Duration of treatment for Acute Bacterial Conjunctivitis changed to 48 hours after resolution of symptoms. Add hyperlink to Orbital and Periorbital Cellulitis to this section.
6. Fungal	No significant changes
7. Gastrointestinal	Definition of CDI added to the introduction - Detection of C difficile toxin +/- gene alone does not diagnose CDI. Clinical assessment is essential. Asymptomatic colonisation can occur in 20-40% hospitalised inpatients and does not require treatment. Added questions to consider when treating CDI such as; Diarrhoea currently? (≥3 episodes unformed stool within 24 hours), off laxatives for past 24-48 hours? Clinical suspicion of CDI? (e.g. megacolon; severe ileus) CDI categories for first line antibiotics changed to Mild, All other patients and Severe with ileus or toxic megacolon. Clostridioides difficile first or subsequent recurrence or persistent symptoms to contact Micro/ID Vancomycin capsules no longer high tech. Updates to H.pylori eradication antibiotic regimens.
8. Genital system	PID – change in comments to stop IV treatment 24 hours after clinical improvement and continue oral antibiotic therapy for a total duration of 14 days to complete the course. Acute Prostatitis/epididymo-orchitis if sexually active – Change duration to 14 days and remove comment on chlamydia.
9. Intravascular line	No significant changes
10. Malaria	Change to treatment of non-severe malaria in pregnant adult. First line treatment now Riamet® for all trimesters.
11. Neutropenic Sepsis	No Significant changes
12. Obstetrics	Consider country of origin and travel history, particularly travel in areas with risk for transmission of malaria, dengue fever or TB.
13. Respiratory	New comment in the introduction regarding laboratory testing for respiratory viruses should be performed including COVID-19, and, during relevant season, influenza and RSV. Appropriate treatment for COVID-19 or influenza should be initiated if positive. Removed Aspiration pneumonia section. CAP – CURB-65 score 2: Amoxicillin PO/IV for non-smokers with no co-morbidities. Others to get co-amoxiclav PO/IV + clarithromycin. CURB-65 score >3: Remove 14-21days. Addition of steroids in those requiring NIV/MV may improve outcomes, in consultation with Resp/ID. Link Vanc MRSA chapter. Ensure MRSA screen done prior to initiating vancomycin. HAP – Treatment of moderate HAP divided into treatment options in penicillin allergy: CefTRIAXone +/-Gentamicin for delayed onset non-severe reactions and Vancomycin and Ciprofloxacin +/- Gentamicin for immediate or severe delayed reaction. New pathway for treatment of Influenza developed.
14. Sepsis	No significant changes
15. Skin and Soft tissue	Discuss suspected Orbital and Periorbital Cellulitis with Ophthalmology Animal and Human bites prophylaxis duration reduced to 3 days.
16. Throat	Change in agent for the treatment of acute Pharyngitis/Tonsillitis in penicillin allergy to ceftriaxone for delayed onset non-severe reaction and Clindamycin +/- vancomycin for immediate or severe delayed reactions. Clarithromycin no longer recommended. Consider vancomycin for peritonsillar abscess pending cultures.
17. UTI	Change from Co-amoxiclav and Gentamicin for pyelonephritis or complicated UTI (non-pregnancy) to Piperacillin/Tazobactam and Gentamicin. Added comment in the introduction to check GP urine sensitivities from iLab or contact the GP Pyelonephritis or complicated UTI. Up to 3 doses of Gentamicin. Longer duration may be necessary in males-discuss with Micro/ID. 7 days if therapy is with Ciprofloxacin. Added comment in the introduction to prophylaxis for recurrent UTIs that there is limited evidence of any additional benefit from such prophylaxis beyond 6 months.
18. Viral	No significant changes
Antibiotic prophylaxis in surgery	New comments in the introduction. A duration of antibiotic prophylaxis of longer than 48 hours cannot be reasonably justified for any surgical procedure on the basis of current evidence or by consensus of expert opinion. (Note exception: management of open fractures) Antibiotic prophylaxis should not be continued beyond the time frames outlined on the basis that drains remain in place. New section on leech therapy prophylaxis. New section on peritoneal dialysis catheter insertion prophylaxis.
IV to Oral switch therapy	New footnote * under Reasons to avoid/delay switching - Under specialist Micro/ID consultation, some cases may be suitable for IV to PO switch In the table of recommended oral agents – remove flucloxacillin 1g IV and add note to discuss use of oral clindamycin with Micro/ID
Appendix 1 Drug interaction	Added: the Covid therapeutic drug interaction checker
Appendix 2 Guidelines for Management of Patients with an Absent or Dysfunctional Spleen	Removed the table on recommended additional vaccines for adults with functional or anatomical asplenia & hyposplenia and include link to NIAC Immunisation Guidelines for Ireland chapters 3 and 5a
Appendix 3 Chemoprophylaxis for Contacts of Meningococcal & Hib Disease	No significant changes
Appendix 4 Antimicrobial costs	Addition of Meropenem/Vaborbactam
Renal Dosing	Where “usual” appears, change wording to “No dose adjustment required”. Remove table eGFR headings, include as part of each individual monograph. Therapeutic Drug Monitoring (TDM) – Add comment that TDM may be required for isavuconazole, itraconazole, posaconazole and voriconazole. Discuss with Micro/ID Fluconazole- Amend wording to clarify dosing. Give usual dose as loading dose, then give 50% of dose for subsequent doses for eGFR 10-50 Co-trimoxazole- Include wording to clarify that dosing is expressed based on trimethoprim/sulfamethoxazole combination rather than trimethoprim component. Haemodialysis section- Remove vancomycin administration table and add link to IV guide.

Document Version

Version 11: July 2024

Document History
Version date	Document version	Changes from previous version	Edited by
2004	Version 1
May 2006	Version 2	Updated clinical information and compliance with new intranet publication standards	MM/PK
July 2006	Version 2.2	Review by pharmacy for omission errors relating to dosage ROUTES e.g. ciprofloxacin 750mg BD. Complete independent check by two pharmacists	MM/TW
July 2007	Version 3.1	Updated guidelines (clinical information and re-formatting) following meetings of Guideline Development Group.	MC/MM/MT
March 2009	Version 4.1	Updated guidelines (clinical information and re-formatting) following meetings of Guideline Development Group.	MC/MT
July 2010	Version 5	Updated guidelines (clinical information and re-formatting) following meetings of Guideline Development Group.	MT/UNiR
March 2011	Version 5.1	Page 21. Updated treatment of moderate and severe CAP for patients with penicillin allergy. Levofloxacin replaced moxifloxacin as respiratory quinolone on IMB safety advice. Page 37. Amended surgical prophylaxis in cardiothoracic surgery: pacemaker/ICD insertion. If MRSA suspected teicoplanin to replace flucloxacillin. For penicillin allergy removed gentamicin (teicoplanin & gentamicin both still indicated for pulmonary resection).	MT/UNiR
July 2011	Version 5.2	Pages 10-12. Text/layout changes for clarity Pages 54-58. Paediatric guidelines Rev 3 2011 (Updated meningitis guidelines, added meningococcal septicaemia, MCUG prophylaxis & malaria)	MT
July 2012	Version 6	Updated guidelines (clinical information and re-formatting) following meetings of Guideline Development Group.	MT/EMcC
June 2013	Version 6.1	Re-organised content for app development (all sections). Added disclaimer & prescribing principles. Changed CDAD to CDI. Paediatric guidelines Rev 5 (Augmentin dosing)	MT/EMcC
July 2014	Version 7	Updated guidelines following meetings of Guideline Development Group.	MT/DK/EMcC
September 2014	Version 7.1	Paediatric guidelines Rev 6.1 (added maximum doses; modified severe malaria section) Antibiotic Prophylaxis in Surgery: Minor formatting changes	MT/UNiR
December 2014	Version 7.2	Amended renal dosing cefTAROLine, nitrofurantoin, teicoplanin	MT/UNiR
November 2015	Version 7.3	Reserve Antimicrobials & Appendix 1: Red Light pre-authorisation Paediatric guidelines Rev 6.2 (new sections for: Sepsis in neonates admitted from home; Benzylpenicillin for confirmed Group B Strep infection; Adenitis. Updated gentamicin dosing).	MT/MC
July 2016	Version 8	Updated guidelines following meetings of Guideline Development Group.	MT/UNiR
March 2017	Version 8.1	Editing changes in several sections: genital (minor wording change), obstetrics (use booking weight for dosing gentamicin), sepsis (title changed to sepsis source unclear & background note 2 updated), UTI (use booking weight for dosing gentamicin and vancomycin in pregnancy). Summary adult guidelines table updated. Surgical antibiotic prophylaxis: added new urology procedures: transperineal prostatic biopsy & brachytherapy.	MT/UNiR
February 2018	Version 8.2	Reserve antimicrobials – updated policy & added meropenem pre-authorisation Penicillin hypersensitivity - updated definitions H. pylori eradication regimens – new section	MT/UNiR
July 2018	Version 9	Updated guidelines following meetings of Guideline Development Group. Multi-drug Resistant Organism (MDRO) definition CPE definition	DHM/UNiR/MT
April 2019	Version 9.1	Quinolones review and inclusion of warning in prescribing principles	RB/DHM/UNiR
May 2020	Version 9.2	Removal of GUH Paediatric Guidelines. Replaced with link to Children's Health Ireland (CHI) Antimicrobial Guidelines website.	RB/DHM/UNiR
July 2021	Version 10	Updated guidelines following meetings of Guideline Development Group.	RB/DHM/UNiR
July 2024	Version 11	Updated guidelines following meetings of Guideline Development Group.	CL/UNiR/OF

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