Summary Guidelines

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Summary Empiric Antimicrobial Guidelines

  • Doses are for non-obese adults with normal renal and liver function.
  • This is a brief summary guideline. See full guidelines for further sections and information.
  • See footnotes at bottom of table.

Summary Empiric Antimicrobial Guidelines

Infection

1 st Line Antibiotics

Penicillin allergy: delayed onset non-severe reaction

Penicillin allergy: immediate or severe delayed reaction

Duration

Abdomen

The regimens below may NOT cover Multi-drug Resistant Organisms (MRDO) in all cases. See note on MDRO

Intra-abdominal

Mild Community Acquired

Co-amoxiclav IV 1.2g q8h

CefUROXime IV 1.5g q8h

+

Metronidazole** IV 500mg q8h

Ciprofloxacin** IV 400mg q12h +

Metronidazole** IV 500mg q8h

4 to 7 days assuming adequate source control

Moderate to Severe Community Acquired / All Hospital Acquired

Piperacillin/tazobactam IV 4.5g q8h

Add Gentamicin * IV one dose per GAPP App calculator IF haemodynamically unstable

CefTRIAXone IV 2g q24h

+

Metronidazole** IV 500mg q8h

Add Gentamicin * IV one dose per GAPP App calculator IF haemodynamically unstable

Ciprofloxacin** IV 400mg q12h +

Gentamicin * IV one dose per GAPP App calculator +

Vancomycin * IV Infusion dose per GAPP App calculato r +

Metronidazole** IV 500mg q8h

Discuss with Micro/ID.

7 to 10 days assuming adequate source control

Bone & Joint

The regimens below may NOT cover Multi-drug Resistant Organisms (MRDO) in all cases. See note on MDRO

Septic Arthritis

Flucloxacillin IV 2g q6h

OR

Ceftriaxone IV 2g every 24 hours IF high risk of Gram-negative organisms (e.g. elderly; nursing home resident; recurrent UTIs) or risk of gonococcus

Vancomycin * IV Infusion dose per GAPP App calculator

OR Ceftriaxone IV 2g every 24 hours IF high risk of Gram-negative organisms (e.g. elderly; nursing home resident; recurrent UTIs) or risk of gonococcus

Discuss with Microbiology  or Infectious Diseases

Discuss with Microbiology  or Infectious Diseases

Osteomyelitis / Prosthetic Joint Infection

Discuss with Microbiology or Infectious Diseases

Cardiovascular

Bacterial Endocarditis

See full guideline

Central Nervous System

Suspected Bacterial

Meningitis

CefTRIAXone IV 2g q12h

+

Vancomycin * IV Infusion dose per GAPP App calculator

Consider adding

Amoxicillin IV

2g q4h if risk of Listeria

CefTRIAXone IV 2g q12h

+

Vancomycin * IV Infusion dose per GAPP App calculator

Consider adding

Co-trimoxazole IV 60mg/kg

q12h (round dose to nearest multiple of 480mg) if risk of Listeria

Chloramphenicol IV

25mg/kg

+

Vancomycin * IV Infusion dose per GAPP App calculator.

Give 1 st doses, THEN IMMEDIATELY discuss with Micro or ID Consider adding Co-trimoxazole IV 60mg/kg q12h (round dose to nearest multiple of 480mg) if risk of Listeria.

Minimum

7 to 21 days

Suspected Herpes Simplex Encephalitis

Aciclovir IV 10mg/kg q8h (Refer to IV guide for dosing in obese patients)

14 to 21 days

Eye

See full guideline

Fungal

See full guideline

Gastrointestinal

Clostridium difficile infection

See full guideline

Non-Severe Metronidazole PO/NG 400mg q8h

10 to 14 days

Severe Vancomycin PO/NG 125mg q6h

Severe with ileus or toxic megacolon Vancomycin PO/NG 500mg every 6 hours + Metronidazole IV 500mg every 8 hours

Genital system

See full guideline

IV Line

See full guideline

Malaria

See full guideline

Neutropenic Sepsis

See full guideline

Obstetrics

See full guideline

Respiratory System

Community Acquired Pneumonia (including nursing home patients unless history of Multi-drug resistant organisms (MDRO). See note on MDRO )

Signs/symptoms of LRTI AND new consolidation on chest X-ray

Mild CURB-65 Score 0 or 1

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days)

Amoxicillin PO 1g q8h.

- In younger patient ADD Clarithromycin PO 500mg q12h

Doxycycline PO 100mg every 12 hours

Avoid doxycycline in pregnancy or breastfeeding. Discuss with Micro/ID.

Moderate CURB-65 Score 2

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days)

Amoxicillin PO/IV 1g q8h

+

Clarithromycin PO (IV if NPO) 500mg q12h

Levofloxacin PO (IV if NPO) 500mg q12h

Avoid levofloxacin in pregnancy or breastfeeding. Discuss with Micro/ID. Caution if risks for prolonged QT interval

Severe CURB-65 Score ≥ 3

7 days

(longer duration may be required; see full guideline )

Co-amoxiclav IV 1.2g q8h

+

Clarithromycin PO (IV if NPO) 500mg q12h

CefTRIAXone IV 2g q24h

+

Clarithromycin PO (IV if NPO) 500mg q12h

Levofloxacin PO (IV if NPO) 500mg q12h

+ Consider adding Vancomycin * IV Infusion

dose per GAPP App calculator IF risk of S. aureus

Avoid levofloxacin in pregnancy or breastfeeding. Discuss with Micro/ID. Caution if risks for prolonged QT interval

Aspiration Pneumonia (Community Acquired)

NB: Antimicrobial therapy for patients with aspiration without clinical evidence of pneumonia  (acute aspiration pneumonitis) does not offer clinical benefit

Co-amoxiclav IV 1.2g q8h

Discuss with Microbiology or Infectious Diseases

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days)

COPD Exacerbation without infiltrate

Amoxicillin PO 1g q8h

OR If recent (<2/52) course of Amoxicillin:

Co-amoxiclav PO 625mg q8h

Clarithromycin PO 500mg q12h

OR

Doxycycline PO 100mg every 12 hours

Avoid doxycycline in pregnancy or breastfeeding. Discuss with Micro/ID.

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days)

Hospital Acquired Pneumonia

These regimens may NOT cover Multi-drug Resistant Organisms (MRDO) in all cases. See note on MDRO

Contact Micro/ ID for treatment of Pseudomonal infection

Moderate

Piperacillin/tazobactam IV 4.5g q6h

Moderate or severe

Vancomycin * IV Infusion

dose per GAPP App calculator

+

Ciprofloxacin** IV 400mg q12h

If possible aspiration, Add Metronidazole** IV 500mg q8h.

If haemodynamically unstable, Add Gentamicin * IV one dose per GAPP App calculator.

7 days

(longer duration may be required; see full guideline )

Severe (ICU assessment required)

Piperacillin/tazobactam IV 4.5g q6h +

Vancomycin IV infusion, dose per GAPP App calculator. See footnote* re review and monitoring. Review at 24 - 48 hours and stop if MRSA not detected

If haemodynamically unstable Add Gentamicin * IV one dose per GAPP App calculator

Sepsis - See full guideline

The regimens below may NOT cover Multi-drug Resistant Organisms (MRDO) in all cases. See note on MDRO

If haemodynamically unstable

Antibiotics must be given as soon as possible, then discuss with Microbiology or Infectious Diseases.

Meropenem should be considered in patients who are critically ill with sepsis or have a history of a Gram-negative Multi-drug Resistant Organism (MDRO). Discuss use of Meropenem with Microbiology or Infectious Diseases. If meropenem is essential in a patient with a history of severe penicillin allergy e.g. anaphylaxis, close monitoring is required for cross sensitivity e.g. in ICU.

Sepsis-Source Unclear

If source is known or suspected e.g. meningitis, respiratory, urinary, skin and soft tissue, ensure antibiotics are appropriate for the source. Follow the antibiotic recommendations in the corresponding chapter.

For full detailed guidance on the management of sepsis in a pregnant patient, see WAC Directorate Guideline on the Management of Suspected Sepsis and Sepsis in Obstetric Care (QPulse CLN-OGCP-218). Discuss with Obstetrics.

Give antibiotics immediately

No risk factors for MRSA e.g. No CVC/No IV drug use

Discuss with Microbiology or Infectious Diseases

Ciprofloxacin^**IV

400mg q12h

+

Gentamicin ^* IV one dose per GAPP App calculator

+

Vancomycin * IV Infusion

dose per GAPP App calculator

If pregnant or suspected intra-abdominal source

Add Metronidazole IV 500mg q8h

Duration is decided on a case by case basis

Piperacillin/tazobactam IV

4.5g q6h

+

Gentamicin ^* IV

one dose per GAPP App calculator

CefTRIAXone IV 2g q24h

+

Gentamicin ^* IV one dose per GAPP App calculator

If pregnant or suspected intra-abdominal source

Add Metronidazole IV 500mg q8h

CVC/Inflammation at IV catheter site/IV drug use/Risk factors for MRSA

Piperacillin/tazobactam IV

4.5g q6h

+

Gentamicin ^* IV

one dose per GAPP App calculator

+

Vancomycin * IV Infusion

dose per GAPP App calculator

CefTRIAXone IV 2g q24h

+

Gentamicin ^* IV

one dose per GAPP App calculator

+

Vancomycin * IV Infusion

dose per GAPP App calculator

If pregnant or suspected intra-abdominal source Add Metronidazole IV 500mg q8h

Suspected

Meningococcaemia - See full guideline

CefTRIAXone IV 2g q12h

CefTRIAXone IV 2g q12h

Chloramphenicol IV 25mg/kg. Give the first dose & discuss with Micro or ID immediately.

7 days

Skin & Soft Tissue

The regimens below may NOT cover Multi-drug Resistant Organisms (MDRO) in all cases. Vancomycin may be required in addition. See note on MDRO

Cellulitis/

Wound Infection

(Including initial treatment of Mastitis)

NB: If treating mastitis in the lactating woman , see full detailed guidance –including treatment duration - in WAC Directorate Guideline  (QPulse CLN-OGCP-275)

Mild

Flucloxacillin PO 500mg - 1g q6h

CefALEXin PO 500mg q6h

Clindamycin PO 450mg q6h

Duration for mild infection

5 days

Duration for moderate or severe infection

7 to 10 days

Moderate to severe

Flucloxacillin IV 2g q6h

CeFAZolin (Unlicensed) IV 2g q8h

Vancomycin * IV Infusion dose per GAPP App calculator

Severe with incipient necrotising fasciitis

Flucloxacillin IV 2g q6h

+

Clindamycin** IV 600mg q8h

Discuss with Microbiology or Infectious Diseases

Vancomycin * * IV Infusion dose per GAPP App calculator

+

Clindamycin** IV 600mg q8h

For severe, if involving abdominal wall or groin or water exposure, consider adding Ciprofloxacin ** IV 400mg every 12 hours

Diabetic Foot Infection

(without osteomyelitis )

Consider referral to Diabetic Foot Team (ENDF)

Mild

Co-amoxiclav PO 625mg q8h

Clindamycin PO 450mg q6h

Duration:

Minimum 7 days for mild infection.

10 to 14 days in Moderate to Severe infection.

May require up to 3 weeks for severe infection.

Moderate

Co-amoxiclav IV 1.2g q8h

Clindamycin** IV 600mg q8h

+

Ciprofloxacin** IV 400mg q12h

Monitor for diarrhoea

Severe

Piperacillin/tazobactam IV 4.5g q8h

Discuss with Microbiology or Infectious Diseases. See full guideline.

Vancomycin * IV Infusion dose per GAPP App calculator

+

Clindamycin** IV 600mg q8h

+

Ciprofloxacin** IV 400mg q12h

Discuss with Micro or ID. Monitor for diarrhoea.

If risk factors for MRSA in moderate to severe infection consider adding

Vancomycin * * IV Infusion dose per GAPP App calculator

Bites, Animal & Human, Prophylaxis &Treatment

Co-amoxiclav PO 625mg q8h

Metronidazole PO 400mg q8h

+

Doxycycline PO 100mg every 12 hours

Avoid doxycycline in pregnancy or breastfeeding. Discuss with Micro/ID

Duration:

Prophylaxis - 5 days

Treatment - 7 days

Consider need for IV therapy or longer duration if severe infection

Throat

Acute Pharyngitis/

Tonsillitis

Benzylpenicillin IV 1.2g q4h

Clarithromycin** IV 500mg q12h

10 days

Peritonsillar Abscess

Co-amoxiclav IV 1.2g q8h

Ceftriaxone IV 2g q24h

+

Metronidazole** IV 500mg q8h

Clindamycin** IV 600-900mg q8h

7 days

Severe Acute Epiglottitis

CefTRIAXone IV 2g q24h

CefTRIAXone IV 2g q24h

Vancomycin * IV Infusion

dose per GAPP App calculator

+

Ciprofloxacin** IV 400mg q12h

7 to 10 days

Urinary Tract

The regimens below may NOT cover Multi-drug Resistant Organisms (MDRO) in all cases. See note on MDRO

Cystitis/Lower UTI

1 st line antibiotic

Nitrofurantoin PO 50mg q6h

Avoid nitrofurantoin if  eGFR <45 ml/min/1.73 m2. When potential benefit outweighs risk, it may be used with caution if the eGFR is 30–44 ml/min/1.73 m2 for a short course only (3–7 days)

Adjust initial treatment based on culture & sensitivity results.

If eGFR<30ml/ min/1.73m 2 , discuss patients with Microbiology or ID

If pregnant, see WAC Directorate Management of Urinary Tract Infections in Pregnancy (QPulse CLN-OGCP-227)

Duration for non-pregnant women :

3 days for nitrofurantoin

(7 days in males )

Pyelonephritis or complicated UTI

Non-pregnancy

Co-amoxiclav IV 1.2g q8h

+

Gentamicin * IV one dose per GAPP App calculator

CefTRIAXone IV 2g q24h

Add Gentamicin * IV one dose per GAPP App calculator IF haemodynamically unstable

Ciprofloxacin** IV 400mg (or PO 500mg) q12h

Add Gentamicin * IV one dose per GAPP App calculator IF haemodynamically unstable

Minimum 10 days

Acute Pyelonephritis in Pregnancy

CefTRIAXone IV 2g q24h

IF haemodynamically unstable, Add Gentamicin ^* IV one dose per GAPP App calculator (use booking weight)

See full guideline +  full detailed guidance in  WAC Directorate Management of Urinary Tract Infections in Pregnancy (QPulse CLN-OGCP-227)

See full guideline

See full guideline

Viral

See full guideline

* Gentamicin & Vancomycin : Reduce dose in renal impairment. Therapeutic drug monitoring required. Review need for ongoing Gentamicin and Vancomycin on a daily basis.Continue with once daily Gentamicin dosing ONLY if Consultant/Specialist Registrar recommended.

** Ciprofloxacin/Clarithromycin/Clindamycin/Metronidazole IV: Consider oral switch after 24 to 48 hours.

^Gentamicin & Ciprofloxacin are recommended in pregnancy when benefit outweighs risk.