Appendices/Supplementary Information


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Appendix 1: Drug interactions

Appendix 1: Drug interactions

As with all medication, there is potential for interactions when prescribing antimicrobials.

Please review the Prescribing principles prior to prescribing antimicrobials. All antimicrobials should be reviewed for interactions with prescribed medicines at the point of prescribing and discuss with Pharmacy/ID/Microbiology if necessary.

The most important drug-drug interactions occur within the following drugs or classes of drugs:

  • Macrolides, e.g. Clarithromycin and Erythromycin

  • Fluoroquinolones, e.g. Ciprofloxacin

  • Rifamycins, e.g. Rifampicin

  • Azole antifungals, e.g. Fluconazole

  • Antiretrovirals (ARVs)

  • Hepatitis C direct acting agents (DAAs)

  • Linezolid

A list of patients current medication along with any antimicrobials prescribed can be inputted into the following interaction checker:

The following interaction checkers can be used for more specific drug-drug interactions and are available online. Please use the linked sources below to cross check prescribed antimicrobials with prescribed medication. A more extensive list of interaction checkers including Stockleys is available on Medinfo website via hospital network computers only: http://medinfogalway/

If any queries regarding interactions between drugs not available in the above resources please email or bleep the pharmacy team:

See pharmacy contact details for GUH, PUH, RUH, MUH in Information section


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Appendix 2: Antibiotics and Diarrhoea Patient Information Leaflet

Appendix 2: Antibiotics and Diarrhoea Patient Information Leaflet

Copies of the leaflet are available on wards and from Pharmacy

Introduction

Antibiotics are important medicines that can cure serious infections caused by bacteria (germs),

such as bacterial meningitis and pneumonia.  In serious infections antibiotics can be life saving.

Antibiotics do not cure infections caused by viruses (viral infections), like the flu and the common cold.

Antibiotics, like all medicines, have side effects.  These may be mild, such as minor stomach discomfort or may be more serious.

Overuse of antibiotics is a cause for concern as some germs can become resistant to antibiotics if they are prescribed too often. This means that the antibiotic may not work the next time you or someone else takes it.

Using antibiotics is a balance between curing infections and avoiding/reducing the risk of side effects.  It is important to use antibiotics when needed but they must not be used if not essential, so that they can be used to treat infections in the future.

Antibiotic Use in GUH

Galway University Hospitals has antibiotic treatment guidelines that recommend the most suitable antibiotics to use to treat specific infections.  The guidelines take into account the side effects of different antibiotics and the potential risk of promoting Clostridioides difficile infection.

The hospital is committed to safe use of antibiotics, prescribing antibiotics cautiously only when necessary and using them for the shortest effective duration.

Further Information

You can get further information from the HPSC Information Leaflet on Clostridioides difficile or from the Health Protection Surveillance Centre (HPSC) website www.hpsc.ie

Antibiotic Associated Diarrhoea:

  • Many patients require treatment with antibiotics during their hospital stay.

  • Diarrhoea is a common side-effect of antibiotic therapy.

  • In most people, this is mild and settles quickly.

  • In about 1 in 4 people who get diarrhoea after antibiotic treatment, it can be caused by a germ called Clostridioides difficile.

  • Often this also settles quickly without specific treatment.

  • However it can cause more severe diarrhoea in some people, especially if you are over 65 years old or have a serious underlying illness.

  • Symptoms usually start within a few weeks of antibiotic treatment but can still develop up to 3 months later.

Contact your GP or come back to hospital if you have any of the following:

  • The diarrhoea is severe – e.g. more than 4 times a day or lasting for more than 2 days.

  • You have a temperature or feel hot/sweaty etc.

  • You have pain in your tummy.

What will happen next?

A diarrhoea sample will usually be sent to the laboratory for testing.

You may need to have blood tests as well.

Mild cases usually do not need antibiotic treatment.

More severe cases will require an antibiotic.

Rarely patients need to be readmitted to hospital for further management. Your doctor will discuss this with you if this happens to you.


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Appendix 3: Guidelines for Management of Patients with an Absent or Dysfunctional Spleen (Adults)

Appendix 3: Guidelines for Management of Patients with an Absent or Dysfunctional Spleen (Adults)


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Immunisation

Immunisation

  • HSE Immunisation Guidelines for Ireland are regularly updated with online only updates http://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/ Check Chapter 3: Immunisation of immunocompromised persons (updated December 2020) to ensure you have the most up to date guidance.
  • NB: Ideally give required vaccinations at least two weeks, and preferably 4 weeks or more, before splenectomy.
  • For emergency splenectomy or if prior vaccinat ion is overlooked or incomplete, administration at least two weeks after splenectomy is recommended.
  • However, if waiting until 2 weeks post surgery (to optimise immune response to vaccine) take care that vaccination is not missed entirely, especially if the patient is being discharged in the interim.
  • If concerned that the patient may not present to the GP for vaccination or for any other reason, vaccination prior to discharge may merit consideration, even if it is before the required 14 day gap.
  • In general, wait at least 3 months after immunosuppressive chemotherapy or radiotherapy (or give two weeks before such treatment).
  • Where a patient has had a splenectomy in the past, and has not received the required vaccines at the time, they should be immunised at the earliest possible opportunity.
  • When the patient is being sent home, make sure the GP is fully informed about any vaccines required, and the date on which they are due.
  • A patient information leaflet is also available from the link https://www.gov.uk/government/publications/splenectomy-leaflet-and-card

Recommended additional vaccines for adults with functional or anatomical asplenia & hyposplenia; check routine immunisation from birth and boosters have been given

Please check HSE Immunisation Guidelines for Ireland /Chapter 3: Immunisation of immunocompromised persons (updated December 2020) to ensure you have the most up to date guidance http://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/

Vaccine

Brand name

Please check HSE Immunisation Guidelines for Ireland /Chapter 3: Immunisation of immunocompromised persons (updated December 2020) to ensure you have the most up to date guidance http://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/

Meningococcal ACWY (Special order)

Nimenrix ® or Menveo ®

Meningococcal B (Men B)

(Special order)

Bexsero ®

Pneumococcal conjugate vaccine (PCV13)

Prevenar 13 ®

Haemophilis influenza serotype B vaccine (Hib)

Hiberix ®

Pneumococcal polysaccharide vaccine (PPV23)

Pneumovax23 ®

Inactivated influenza

Annually.

Dose: The usual dose is 0.5ml by IM injection. In adults the deltoid is generally the preferred site. Give vaccines at separate injection sites.

Ordering vaccines: Vaccines are supplied by the National Immunisation Office. Men B and Men ACWY vaccines are not routinely available - a special order is required.


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Prophylactic Antibiotics

Prophylactic Antibiotics

  • Recommendations regarding the duration of antibiotic prophylaxis for asplenia and hyposplenia vary. The risk for invasive pneumococcal infection is elevated throughout life but highest for those <16 and >50 years of age.
  • All patients should receive prophylactic antibiotics for a minimum of one to two years post splenectomy.
  • Lifelong prophylaxis is recommended for high-risk patients. See risk factors below.
  • Risk assessment is recommended for low risk patients. Such patients should be counselled regarding the risks and benefits of lifelong antibiotics and may choose to discontinue prophylaxis. Prophylaxis should only be discontinued if the patient is fully immunised and education and counselling is given regarding the risks of pneumococcal, meningococcal and Haemophilus B infection and the need for prompt early management of febrile illness.

Risk factors associated with high risk of invasive pneumococcal disease in hyposplenism include:

  • Immediate post-operative period
  • Age less than 16 or greater than 50 years
  • Inadequate serological response to pneumococcal vaccination
  • A history of previous invasive pneumococcal disease
  • Splenectomy for underlying haematological malignancy particularly in the context of on-going immunosuppression
  • Poor clinic attendees
  • Patients with sickle cell disease with surgical splenectomy

Prophylactic Antibiotics for Adult Patients with an Absent or Dysfunctional Spleen

Infection

First line antibiotics

If penicillin allergy

Comment

Prophylaxis for patients with an absent or dysfunctional spleen

Phenoxymethylpenicillin 666mg (Calvepen ® ) every 12 hours

or Amoxicillin PO 500mg every 24 hours

Erythromycin PO 250 to 500mg every 24 hours

Oral absorption of phenoxymethylpenicillin is limited and affected by a number of variables. For emergency self initiated therapy of a suspected systemic infection treatment doses of amoxicillin are preferable.

Treatment doses

Amoxicillin PO 500mg to 1g every 8 hours

Erythromycin PO 500mg to 1g every 6 hours

Amoxicillin advantages: absorption not affected by food, broader spectrum

A supply of treatment doses of amoxicillin should be kept at home (and on holidays) and used immediately should infective symptoms of raised temperature or malaise develop. In such a situation, the patient should seek urgent medical attention


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Patient Education & Documentation

Patient Education & Documentation

  • Patients developing infection, despite measures, must be given systemic antibiotics and admitted urgently to hospital.
  • Patients should be given written information and carry a card to alert health professionals to the risk of overwhelming infection. Patients may wish to invest in alert bracelet or pendant.
  • Patients should be educated as to the potential risks of overseas travel, particularly regarding malaria and unusual infections, for example resulting from animal bites. Co-amoxiclav (or appropriate alternative in penicillin allergy) is recommended after animal bites.
  • The front cover of patient records should be clearly labelled to indicate the underlying risk of infection from absent or dysfunctional spleen.
  • Vaccination and revaccination status should be clearly and adequately documented.
  • It may be appropriate to advise people that they are at risk of infection with the agent associated with red water fever in cattle and that they should take precaution against tick exposure (wear protective clothing in tick infested areas) when walking in the countryside.


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References

References

1. Immunisation Guidelines for Ireland http://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/

- Chapter 3 – Immunisation of immunocompromised persons (updated Dec 2020)

- Chapter 16 – Pneumococcal infection (updated July 2018)

- Chapter 13 – Meningococcal infection (updated October 2019)

2. Davies et al. Review of guidelines for the prevention and treatment of infection in            patients with an absent or dysfunctional spleen: Prepared on behalf of the British Committee for Standards in Haematology by a Working party of the Haemato-Oncology Task Force British Journal of Haematology 2011;155:208-317

3. IDSA Clinical Guidelines for Vaccination of the Immunocompromised Host 2013


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Appendix 4: Chemoprophylaxis for Contacts of Meningococcal & Hib Disease

Appendix 4: Chemoprophylaxis for Contacts of Meningococcal & Hib Disease

Public Health & GUH Microbiology, Infectious Diseases & Pharmacy Depts

Updated November 2020


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Management of Contacts of Meningococcal Disease (Meningitis/Septicaemia)

Management of Contacts of Meningococcal Disease (Meningitis/Septicaemia)

  1. Immediately notify all cases of suspected invasive meningococcal disease to the local Public Health Department 091-775200 (contact out-of-hours through Ambulance Control), without waiting for microbiological confirmation.
  2. Public Health will advise on the management of contacts and suspected outbreaks.
  3. Close contacts of all cases of invasive meningococcal disease are at increased risk of developing infection. This risk is highest in the first 7 days following onset of symptoms in the index case.
  4. Chemoprophylaxis should be offered to close contacts irrespective of vaccination status and should be given as soon as possible after notification of the index case, preferably within 24 hours of diagnosis but can be given up to one month later if a contact is not immediately identified or traced.
  5. The following is provided for information in relation to close contacts who should be offered chemoprophylaxis:
  • Household-type contacts in the seven days prior to the onset of illness of the index case e.g.
    • shared living/sleeping accommodation with the index case, pupils in the same dormitory, boy/girlfriend, university students sharing kitchen in a hall of residence, child-minders and baby-sitters.
    • Intimate mouth to mouth kissing contacts with the index case
    • Nursery/crèche contacts where the nature of contact is similar to that for household contacts, including adult carers
    • Other situations with possible close contact (e.g. attendance at house party, classmates, extended family) may also warrant prophylaxis in certain circumstances as advised by Public Health
  • Health Care Workers (HCWs) (including those present at autopsy) whose mouth and nose is directly exposed to respiratory droplets or secretions of a probable or confirmed case within 24 hours of commencement of antibiotics i.e. those carrying out high risk procedures and when within one metre of the patient. HCWs should wear masks when in close contact with an infectious case in the first 24 hours after starting antibiotic treatment. Occupational Health should be contacted if necessary.
  • The index case should be given chemoprophylaxis before discharge from hospital UNLESS treated with cefTRIAXone.

6. Prophylactic antibiotics

  • Chemoprophylaxis packs for close contacts are available in Emergency Department, Paediatric Department and the Pharmacy Department. Recipients should be given information on symptoms and signs of the disease and the need to seek urgent medical advice should they become unwell, even if they have already received chemoprophylaxis.This information is included in the patient information leaflet provided with the chemoprophlyaxis packs.
  • Rifampicin and Ciprofloxacin are both recommended for chemoprophylaxis except for the following:
    • Women taking hormonal contraceptives – ciprofloxacin is the preferred option as rifampicin can affect the efficacy of these contraceptives.
    • For pregnant women Ciprofloxacin is the preferred option.
  • Please refer to most recent SPC available at www.hpra.ie for contraindications , allergies or potential drug interaction s for these antibiotics. See below for summary information. Ceftriaxone may be used as an alternative option.

Ciprofloxacin:

  • Ciprofloxacin can be used in all age groups and for the majority of the population (except for those with contraindications). It is the antibiotic of choice for those on the oral contraceptive pill. It may be particularly useful when there is a setting with a large number of adult contacts (e.g. university students). Ciprofloxacin has a number of advantages over rifampicin. It is given as a single dose. It does not interact with systemic hormonal contraceptives. It is more readily available in community pharmacies and does not affect contact lenses.
  • The summary of product characteristics (SPC) for ciprofloxacin carries a precaution on its use in pregnancy – “As a precautionary measure, it is preferable to avoid the use of ciprofloxacin during pregnancy”. However, short duration treatment for other indications appeared to be safe. It is recommended for use in pregnancy and lactation by Public Health England.
  • Contraindicated with tizanidine, caution in epilepsy and in combination with theophylline.
  • Adult Dose is a single oral dose of 500mg

Rifampicin:

  • Rifampicin can be used in all age groups and for the majority of the population (except for those with contraindications).
  • Rifampicin is contraindicated in the presence of jaundice, severe liver disease or in combination with saquinavir/ritonavir (antiretroviral drugs).
  • Caution with drugs metabolised by cytochrome P-450. These drugs include anticoagulants, anticonvulsants, and hormonal contraceptives.
  • When administered during the last few weeks of pregnancy, rifampicin can cause post-natal haemorrhages in the mother and infant, for which treatment with Vitamin K1 may be indicated for both mother and neonate.
  • Written information on side effects of rifampicin and interaction with food should be provided and explained to patient including red colouration of urine, sweat and tears, and permanent discolouration of soft contact lenses.
  • Adult Dose is 600mg every 12 hours for two days

Ceftriaxone:

  • In pregnancy : CefTRIAXone (single 250mg intramuscular dose) can be used.
  • Ceftriaxone should not be used for chemoprophylaxis in infants in the first 4 weeks of life.

For more comprehensive guidance see Chapter 13 in Immunisation Guidelines for Ireland


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Management of Contacts of Invasive Haemophilus Influenzae B Disease

Management of Contacts of Invasive Haemophilus Influenzae B Disease

  1. Immediately notify all cases of suspected invasive meningococcal disease to the local Public Health Department 091-775200 (contact out-of-hours through Ambulance Control), without waiting for microbiological confirmation.
  2. Public Health will advise on the management of contacts and suspected outbreaks.
  3. The following is provided for information :
    • Chemoprophylaxis: Indicated for all household contacts (irrespective of age or immunisation history) in the following situations:
      • If there are any unvaccinated or incompletely vaccinated children under the age of 10 years
      • If there are any persons at increased risk of invasive Hib disease (asplenia, hyposlenism, immunocompromised etc.)
    • Play-group, crèche or school contacts aged less than 10 years: when 2 or more cases occur within 2 months, chemoprophylaxis should be offered to all room contacts, both adults and children.
    • Index patients aged <10 years not treated with ceftriaxone or cefotaxime should receive rifampicin prior to hospital discharge. Index cases of any age not treated with ceftriaxone or cefotaxime should receive rifampicin prophylaxis prior to hospital discharge if there is a vulnerable individual in the household.
    • Vaccination: In addition to prophylaxis, unvaccinated or partially vaccinated contacts should complete the age-appropriate vaccination schedule.
  4. For more comprehensive guidance see Immunisation Guidelines for Ireland
  5. Antibiotic doses for prophylaxis:
  • Rifampicin - Adult Dose (including if pregnant or breastfeeding) – 20mg/kg once daily for 4 days (max. 600 mg/day).
  • Ceftriaxone - Ceftriaxone can be given if rifampicin is contraindicated. Recommended dose is 50mg/kg (max 1g) IM or IV once daily for 2 days.


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References

References

1. Immunisation Guidelines for Ireland www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/

Chapter 13 – Meningococcal infection (updated October 2019)

Chapter 7- Haemophilus influenzae type b (updated July 2018)

2. HPSC Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including meningococcal disease) (updated November 2016)


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Appendix 5: Antimicrobial Costs

Appendix 5: Antimicrobial Costs

Indicative Cost: Most frequently prescribed antimicrobials

IV Antimicrobials

Cost per day

Oral Antimicrobials

Cost per day

Piperacillin/tazobactam 4.5g qds

<€15

Co-amoxiclav 1.2g tds

<€10

Co-amoxiclav 625mg tds

<€1

Vancomycin  1g bd

<€10

Meropenem 1g tds

€10 to €50

Ciprofloxacin 400mg bd

<€10

Ciprofloxacin 500mg bd

<€1

Fluconazole 200mg od

<€10

Fluconazole 200mg od

<€1

Flucloxacillin 1g qds

€10

Flucloxacillin 500mg qds

<€1

Cefuroxime 750mg tds

<€10

Cefuroxime 500mg bd

<€1

Metronidazole 500mg tds

<€10

Metronidazole 400mg tds

<€1

Ceftriaxone 2g od

€10 to €20

Co-trimoxazole 960mg bd

<€10

Co-trimoxazole 960mg bd

<€1

Levofloxacin 500mg bd

<€10

Levofloxacin 500mg bd

€1 to €5

Linezolid 600mg bd

€10 to €50

Linezolid 600mg bd

€5 to €10

Clarithromycin 500mg bd

€10 to €20

Clarithromycin 500mg bd

<€1

Gentamicin 360mg od

<€10

Nitrofurantoin 100mg qds

<€1

Clindamycin 600mg tds

€10 to €20

Clindamycin 300mg qds

€1 to €5

Trimethoprim 200mg bd

<€1

Azithromycin 250mg od

€1 to €5

Doxycycline 100mg bd

<€1

Indicative Cost: Most expensive antimicrobials

IV Antimicrobials

Cost per day

Oral Antimicrobials

Cost per day

Ambisome 250mg od

€500 to €1000

Anidulafungin 100mg od €100 to €500

Posaconazole 300mg od

€500 to €1000

Posaconazole 300mg od

€50 to €100

Caspofungin 50mg od

€50 to €100

Ceftaroline 600mg bd €100 to €500
Ceftazidime/avibactam tds €250 to €500
Ceftolozane/tazobactam tds €750 to €1500

Daptomycin 500mg od

€100 to €500

Tigecycline 50mg bd

€100 to €500

Voriconazole 280mg bd

€100 to €500

Voriconazole 200mg bd

<€10

Costs are for an average treatment dose, and are inclusive of hospital discounts and VAT